source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCTBI3.m@ 1384

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