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1DVBCTBI3 ;ALB/RLC TRAUMATIC BRAIN INJURY (TBI) WKS TEXT - 2 ; 12 FEB 2007
2 ;;2.7;AMIE;**125**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;C. Physical Examination (Objective Findings):
7 ;;
8 ;; Address each of the following and fully describe current findings:
9 ;;
10 ;; 1. Motor function. Report the motor strength of the affected muscles
11 ;; of all areas of weakness or paralysis using the standard muscle
12 ;; grading scale, for example, weakness of flexion of left elbow
13 ;; (3/5 strength for flexors), complete paralysis of left lower
14 ;; extremity (0/5 for all muscle groups). To the extent possible,
15 ;; identify the peripheral nerves that innervate the weakened or
16 ;; paralyzed muscles.
17 ;;
18 ;; Standard muscle grading scale:
19 ;;
20 ;; 0=Absent No muscle movement felt.
21 ;; 1=Trace Muscle can be felt to tighten, but no movement produced.
22 ;; 2=Poor Muscle movement produced only with gravity eliminated.
23 ;; 3=Fair Muscle movement produced against gravity, but cannot
24 ;; overcome any resistance.
25 ;; 4=Good Muscle movement produced against some resistance, but
26 ;; not against "normal" resistance.
27 ;; 5=Normal Muscle movement can overcome "normal" resistance.
28 ;;
29 ;; 2. Muscle tone, reflexes. Describe any muscle atrophy or loss of
30 ;; muscle tone. Examine and report deep tendon reflexes and any
31 ;; pathological reflexes.
32 ;; 3. Sensory function. Describe exact location of any area of abnormal
33 ;; sensory function. State which modalities of sensation were tested.
34 ;; 4. Gait, cerebellar signs. Describe any gait abnormality, imbalance,
35 ;; tremor or fasciculations, incoordination, or spasticity. If there
36 ;; is spasticity or rigidity, assess any limitation of motion of
37 ;; joint (including joint contracture) by following the Joints
38 ;; examination protocol. (A tandem gait assessment (walking in a
39 ;; straight line with one foot directly in front of the other) is
40 ;; recommended).
41 ;; 5. Autonomic nervous system. Describe any other impairment of the
42 ;; nervous system, such as orthostatic hypotension, hyperhidrosis.
43 ;; 6. Cranial nerves. Conduct a screening exam for cranial nerve
44 ;; impairment. If positive, follow Cranial Nerves examination
45 ;; protocol.
46 ;; 7. Cognitive impairment. Conduct a screening examination (such as
47 ;; Mini-mental State Examination) to assess cognitive impairment and
48 ;; report results and their significance. Does the screening show
49 ;; problems with memory, concentration, attention, information
50 ;; processing, aggressiveness, decreased spontaneity, etc.? If yes,
51 ;; have these been confirmed by prior special examinations, such as
52 ;; neuropsychological testing? If not, are these indicated? If
53 ;; cognitive abnormalities are found, claimed, or suspected, request
54 ;; a Mental Disorder examination protocol by a mental disease
55 ;; specialist.
56 ;; 8. Psychiatric manifestations. Conduct a screening examination for
57 ;; psychiatric manifestations, including emotional behavior. If a
58 ;; mental disorder is suggested, request a mental disorder exam or
59 ;; PTSD exam, as appropriate, by a mental disease specialist.
60 ;; 9. Vision and hearing screening examinations (if abnormalities are
61 ;; found, or there are symptoms or a claim of eye or ear impairment,
62 ;; request an eye or audio exam by a specialist).
63 ;; 10. Skin. Describe any areas of skin breakdown due to neurologic
64 ;; problems.
65 ;; 11. Endocrine dysfunction. Describe any evidence of endocrine
66 ;; dysfunction due to TBI.
67 ;; 12. Oral and dental screening examination. Describe jaw malalignment,
68 ;; cracked or missing teeth, etc., and refer for special Dental and
69 ;; Oral examination when indicated.
70 ;; 13. Other abnormal physical findings.
71 ;;
72 ;;D. Diagnostic and Clinical Tests:
73 ;;
74 ;; 1. Skull X-rays to measure bony defect, if any, due to surgery or
75 ;; injury.
76 ;; 2. Include results of all diagnostic and clinical tests conducted in
77 ;; the examination report.
78 ;;
79 ;;E. Diagnosis:
80 ;;
81 ;; 1. List each diagnosis.
82 ;; 2. Capacity to manage financial affairs.
83 ;; Mental competency, for VA benefits purposes, refers only to the
84 ;; ability of the veteran to manage VA benefit payments in his or her
85 ;; own best interest, and not to any other subject.
86 ;; Mental incompetency, for VA benefits purposes, means that the
87 ;; veteran, because of injury or disease, is not capable of managing
88 ;; benefit payments in his or her own best interest. In order to
89 ;; assist raters in making a legal determination as to competency,
90 ;; please address the following:
91 ;;
92 ;; a. What is the impact of injury or disease on the veteran's ability
93 ;; to manage his or her financial affairs, including consideration
94 ;; of such things as knowing the amount of his or her VA benefit
95 ;; payment, knowing the amounts and types of bills owed monthly,
96 ;; and handling the payment prudently? Does the veteran handle
97 ;; the money and pay the bills himself or herself?
98 ;; b. Based on your examination, do you believe that the veteran is
99 ;; capable of managing his or her financial affairs? Please
100 ;; provide examples to support your conclusion.
101 ;; c. If you believe a Social Work Service assessment is needed
102 ;; before you can give your opinion on the veteran's ability to
103 ;; manage his or her financial affairs, please explain why.
104 ;;
105 ;;
106 ;;
107 ;;Signature: Date:
108 ;;END
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