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1DVBCWBS1 ;ALB/CMM BRAIN AND SPINAL CORD WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. If flare-ups exist, describe precipitating factors,
14 ;; aggravating factors, alleviating factors, alleviating
15 ;; medications, frequency, severity, duration, and whether the
16 ;; flare-ups include pain, weakness, fatigue, or functional loss.
17 ;;
18 ;;
19 ;; 2. Current treatment, response, and side effects.
20 ;;
21 ;;
22 ;; 3. State whether condition has stabilized.
23 ;;
24 ;;
25 ;; 4. Seizures - type, frequency.
26 ;;
27 ;;
28 ;; 5. Headache, dizziness, etc.
29 ;;
30 ;;
31 ;;C. Physical Examination (Objective Findings):
32 ;;
33 ;; Address each of the following and fully describe current findings:
34 ;; 1. If a tumor is or was present, note location, type, and
35 ;; whether or not it is malignant. If a malignancy is present
36 ;; but is now cured or in remission, report the date of last
37 ;; surgery, radiation therapy, chemotherapy, or other treatment.
38 ;;
39 ;;
40 ;; 2. Describe in detail the motor and sensory impairment of all
41 ;; affected nerves.
42 ;;
43 ;;
44 ;; 3. Describe in detail any functional impairment of the peripheral
45 ;; and autonomic systems.
46 ;;
47 ;;TOF
48 ;; 4. A DETAILED ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED.
49 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
50 ;; of motion, including movement against gravity and against
51 ;; strong resistance.
52 ;;
53 ;;
54 ;; b. If the joint is painful on motion, state at what point in
55 ;; the range of motion pain begins and ends.
56 ;;
57 ;;
58 ;; c. State to what extent, if any, the range of motion or
59 ;; function is ADDITIONALLY LIMITED by pain, fatigue, weakness,
60 ;; or lack of endurance. If more than one of these is
61 ;; present, state, if possible, which has the major
62 ;; functional impact.
63 ;;
64 ;;
65 ;; 5. Describe any psychiatric manifestations in detail - see
66 ;; worksheets for mental disorders.
67 ;;
68 ;;
69 ;; 6. Eye examination.
70 ;;
71 ;;
72 ;; 7. State if the veteran has bladder or bowel functional impairment.
73 ;; If present, state whether partial or total, intermittent or
74 ;; constant and what measures are taken as a result of the impairment.
75 ;;
76 ;;
77 ;; 8. State if the veteran is capable of managing his or her benefit
78 ;; payments in his or her own best interest without restriction.
79 ;; (A physical disability which prevents the veteran from attending
80 ;; to financial matters in person is not a proper basis for a
81 ;; finding of incompetency unless the veteran is, by reason of
82 ;; that disability, incapable of directing someone else in
83 ;; handling the individual's financial affairs.)
84 ;;
85 ;;
86 ;; 9. If smell or taste is affected, also complete the appropriate
87 ;; worksheet.
88 ;;
89 ;;
90 ;;D. Diagnostic and Clinical Tests:
91 ;;
92 ;; 1. Skull X-rays to measure bony defect, if there was surgery;
93 ;; spine X-rays if there was spinal cord surgery.
94 ;; 2. Include results of all diagnostic and clinical tests conducted
95 ;; in the examination report.
96 ;;
97 ;;E. Diagnosis:
98 ;;
99 ;;
100 ;;Signature: Date:
101 ;;END
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