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Routine: DVBCWBS3

DVBCWBS3.m

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DVBCWBS3 ;ALB/RLC BRAIN AND SPINAL CORD WKS TEXT - 1 ; 6 MARCH 1997

 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8

 ;

 ;

TXT ;

 ;;Narrative:  In some cases, assessment of the residuals of brain or spinal

 ;;cord disease or injury will require following examination worksheets in other

 ;;body systems or referring for a specialist examination (for Eye, Hearing,

 ;;or Mental Disorders).  For example, bladder impairment may require assessment

 ;;under the Genitourinary worksheet guidelines.  Vision problems will require a

 ;;specialist eye examination.  Other examination worksheets for the nervous

 ;;system (cranial nerves, peripheral nerves, epilepsy and narcolepsy) may need

 ;;to be followed for thorough assessment.

 ;;

 ;;A.  Review of Medical Records:  Indicate whether the C-file was reviewed.

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Comment on:

 ;;

 ;;    1.  History of surgery or hospitalizations, reason or type of surgery,

 ;;        location and dates, if known.

 ;;    2.  History of trauma to brain or spinal cord.  If there is a history of

 ;;        traumatic brain injury in service, follow the Traumatic Brain Injury

 ;;        worksheet.

 ;;    3.  If a neoplasm is or was present, state whether benign or malignant

 ;;        and provide:

 ;;

 ;;        a.  Exact diagnosis and date of confirmed diagnosis.

 ;;        b.  Location of neoplasm.

 ;;        c.  Types and dates of treatment.

 ;;        d.  For malignant neoplasm, also state exact date of the last

 ;;            surgical, X-ray, antineoplastic chemotherapy, radiation, or other

 ;;            therapeutic procedure.

 ;;        e.  If treatment is already completed, provide date of last treatment

 ;;            and fully describe residuals.  If not completed, state expected

 ;;            date of completion.

 ;;

 ;;    4.  Current treatment, response, and side effects.

 ;;    5.  State whether condition has stabilized.

 ;;    6.  Seizures - type, frequency.  Follow the Epilepsy worksheet.

 ;;    7.  Headache (frequency, duration, severity); dizziness (frequency and

 ;;        severity); fever; weakness or paralysis (location); dysesthesias,

 ;;        numbness, or paresthesias (location); fatigability (frequency).

 ;;    8.  Tremors (location), gait difficulty (frequency), rigidity.

 ;;    9.  Difficulty swallowing:  extent (liquids, solids, or both); severity

 ;;        (feeding tube, liquid diet, etc.); episodes of aspiration per year,

 ;;        if any.

 ;;    10. Impairment of bowel function:  for constipation, frequency (occasional,

 ;;        frequent, constant), measures needed (bowel training, manual

 ;;        evacuation, enemas, suppositories, medication, etc.); for incontinence

 ;;        (pads required?), extent (mild, moderate, severe) and frequency

 ;;        (occasional leakage, occasional involuntary bowel movement, frequent

 ;;        involuntary bowel movement, persistent loss of sphincter control).

 ;;    11. Impairment of bladder function:  type (urgency, continual urine

 ;;        leakage, urinary incontinence, leakage due to surgical urinary

 ;;        diversion, stress incontinence, etc.), requirement for constant or

 ;;        intermittent catheterization or use of an appliance, wearing of

 ;;        absorbent material (number of times that must be changed daily).

 ;;    12. Impairment of sense of smell or taste:  Follow Sense of Smell and

 ;;        Taste worksheet.

 ;;    13. Difficulty breathing.

 ;;    14. Vision symptoms:  Follow Eye worksheet.

 ;;    15. Insomnia:  frequency.

 ;;    16. Tinnitus:  constant or recurrent?

 ;;    17. Speech problems.

 ;;    18. Cognitive impairment:  If related to traumatic brain injury, follow

 ;;        Traumatic Brain Injury worksheet; otherwise follow Mental Disorders

 ;;        worksheet.

 ;;    19. History of cerebrovascular accident:  type, if known, and date.

 ;;    20. Assistive device needed for walking:  type (cane(s), brace, crutch(es),

 ;;        walker).

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Address each of the following and fully describe current findings:

 ;;

 ;;    1.  If a neoplasm is or was present, describe residuals of the neoplasm

 ;;        and its treatment.

 ;;    2.  Describe specific functional motor impairment of affected areas (for

 ;;        example, weakness of flexion of left elbow (3/5 strength for flexors),

 ;;        complete paralysis (0/5) of all muscle groups of left lower extremity).

 ;;        Use standard muscle strength grading system:  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 resistance; 4 = good.  Muscle movement

 ;;        produced against some resistance, but not against "normal" resistance;

 ;;        5 = normal.  Muscle movement can overcome "normal" resistance.

 ;;    3.  Describe abnormality of muscle tone and any muscle atrophy (give left

 ;;        and right side measurements).

 ;;    4.  Reflexes.  Use deep tendon reflex grading system (0 = absent, 1+ =

 ;;        hypoactive, 2+ = normal, 3+ = hyperactive, without clonus, 4+ =

 ;;        hyperactive, with clonus).  Report bilateral reflexes of biceps (C5-6),

 ;;        triceps (C6-8), brachioradialis (C5-6), finger jerk (C8-T1), abdominal

 ;;        (T8-T12), knee jerk (L3-4), ankle jerk (S1), plantar (Babinski).

 ;;    5.  If there is loss of sensory function of a nerve or group of nerves,

 ;;        report the location, modality of sensation affected, and whether

 ;;        decreased or absent.

 ;;    6.  If cranial nerve function is affected, follow the Cranial Nerves

 ;;        worksheet.

 ;;    7.  Describe in detail any functional impairment of the autonomic nervous

 ;;        system.

 ;;    8.  If there is limitation of motion of one or more joints, a detailed

 ;;        assessment of each affected joint is required.

 ;;

 ;;        Using a goniometer, measure the active range of motion in degrees.

 ;;        State whether there is objective evidence of pain on motion.  After

 ;;        at least 3 repetitions of the range of motion, state whether there

 ;;        are additional limitations of range of motion and whether there is

 ;;        objective evidence of pain on motion.  Also state the most important

 ;;        factor (pain, weakness, fatigue, lack of endurance, incoordination)

 ;;        for any additional loss of motion after repetitive motion.  Report

 ;;        the range of motion after the repetitions.  (See the appropriate

 ;;        musculoskeletal worksheet for more details.).

 ;;    9.  If there is speech impairment, state to what extent veteran is able

 ;;        to be understood (unable to be understood, able to be understood less

 ;;        than half the time, able to be understood half of the time or more

 ;;        but not always, able to be understood all of the time except for a

 ;;        few words or only occasionally not understood).

 ;;    10. Describe any psychiatric or cognitive manifestations in detail - see

 ;;        worksheets for mental disorders (but when traumatic brain injury is

 ;;        present, also see the Traumatic Brain Injury worksheet to assess

 ;;        cognitive impairment).

 ;;    11. Describe tremors or fasciculation, gait, balance, cerebellar signs.

 ;;    12. Eye examination - follow Eye worksheet.  Requires specialist to

 ;;        conduct examination if there are eye complaints or findings.

 ;;    13. State if the veteran has bladder or bowel functional impairment.  For

 ;;        bowel impairment, state whether leakage is evident and the status of

 ;;        the sphincter (normal, decreased tone, absent tone).  For bladder

 ;;        impairment, state whether leakage is evident and describe any

 ;;        complications (follow the Genitourinary worksheet if indicated).

 ;;    14. If smell or taste is affected, also complete the worksheet for Sense

 ;;        of Smell and Taste.

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  Skull X-rays to measure bony defect, if there was surgery; 

 ;;        spine X-rays if there was spinal cord surgery.

 ;;    2.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;    1.  State diagnosis or diagnoses.

 ;;    2.  For each condition diagnosed, describe the effects on the veteran's

 ;;        usual occupation and daily activities.

 ;;    3.  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:

 ;;

 ;;        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?

 ;;

 ;;        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.

 ;;

 ;;        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