source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCTBI3.m@ 1742

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