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Routine: DVBCTBI3

DVBCTBI3.m

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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