[613] | 1 | DVBCPRCK ;ALB/GTS-557/THM-THE PERIPHERAL NERVES EXAM ; 12/27/90 1:32 PM
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| 2 | ;;2.7;AMIE;;Apr 10, 1995
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| 3 | ;
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| 4 | S PG=1,HD91="Department of Veterans Affairs",HD9=$S($D(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
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| 5 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 6 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1230 Worksheet" S HD7="THE PERIPHERAL NERVES",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 7 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
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| 8 | W !!!!,"Narrative: None",!!
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| 9 | W !! I '$D(CMBN) W "A. Medical history:",!!!!!!!!!!,"B. Subjective complaints:",!!!!!!!!!!,"C. Objective findings:" D HD2
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| 10 | W $S($D(CMBN):"A. ",1:"D. "),"Specific evaluation information required by the rating board",!?4,"(if the information requested is included elsewhere, do not",!?4,"repeat here):",!!!
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| 11 | S LX="TXT1" F I=1:1 S LY=$T(@LX+I) Q:LY["END" W $P(LY,";;",2),!
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| 12 | D:$D(CMBN) HD2 S LX="TXT2" F I=1:1 S LY=$T(@LX+I) Q:LY["END" W $P(LY,";;",2),!
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| 13 | D:'$D(CMBN) HD2 W $S($D(CMBN):"B. ",1:"E. "),"Diagnostic/clinical test results:",!!!!!!!!!!!!!!
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| 14 | W $S($D(CMBN):"C. ",1:"F. "),"Diagnosis:",!!!!!!!!!!!!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 15 | K LN,LN1,LN2
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| 16 | Q
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| 17 | ;
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| 18 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for ",NAME,!!!
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| 19 | Q
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| 20 | ;
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| 21 | SETIOF ; ** Set device control var's
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| 22 | D HOME^%ZIS
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| 23 | Q
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| 24 | ;
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| 25 | TXT1 ;
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| 26 | ;; 1. Where disability is the result of brain disease or injury, spinal cord
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| 27 | ;; disease or injury, cervical disc disease, or trauma to the nerve roots
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| 28 | ;; themselves, report sensory and motor impairment by reference to the
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| 29 | ;; distribution of the affected groups as paralysis, neuritis or
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| 30 | ;; neuralgia. Report each affected extremity separately -
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| 31 | ;;
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| 32 | ;;
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| 33 | ;; a. In the upper extremities -
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| 34 | ;;
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| 35 | ;;
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| 36 | ;;
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| 37 | ;;
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| 38 | ;;
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| 39 | ;;
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| 40 | ;;
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| 41 | ;; b. In the lower extremities -
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| 42 | ;;
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| 43 | ;;
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| 44 | ;;
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| 45 | ;;
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| 46 | ;;
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| 47 | ;;
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| 48 | ;;
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| 49 | ;;
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| 50 | ;;END
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| 51 | TXT2 ;
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| 52 | ;; 2. Where disability is NOT from the above, identify the specific major
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| 53 | ;; nerve involved, localize the lesion and describe specific impairment
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| 54 | ;; of motor and sensory function, fine motor control, etc.. Again
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| 55 | ;; characterization as paralysis, neuritis or neuralgia is necessary
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| 56 | ;; Indicate whether any muscle wasting or atrophy represents direct
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| 57 | ;; effect of nerve damage or merely disuse. Report each affected
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| 58 | ;; extremity separately -
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| 59 | ;;
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| 60 | ;;
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| 61 | ;; a. In the upper extremities -
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| 62 | ;;
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| 63 | ;;
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| 64 | ;;
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| 65 | ;;
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| 66 | ;;
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| 67 | ;;
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| 68 | ;;
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| 69 | ;;
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| 70 | ;; b. In the lower extremities -
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| 71 | ;;
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| 72 | ;;
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| 73 | ;;
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| 74 | ;;
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| 75 | ;;
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| 76 | ;;
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| 77 | ;;
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| 78 | ;;
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| 79 | ;;END
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