Tbi C&p Exam

manni · December 18, 2014

Here is my TBI C&P which lasted 20 minutes only. I'm thinking of 0%-10%. Thanks in advance

Muscle Injuries

Disability Benefits Questionnaire

Indicate method used to obtain medical information to complete this

document:

[X] In-person examination

Evidence review

---------------

Was the Veteran's VA claims file reviewed?

[ ] Yes[X] No

If no, check all records reviewed:

[X] Veterans Health Administration medical records (VA treatment records)

E-FOLDER ON VBMS.

SECTION I: DIAGNOSIS

--------------------

Does the Veteran now have or has he/she ever been diagnosed with a muscle injury?

[X] Yes[ ] No

Diagnosis #1: RESIDUALS OF CLOSED LEFT RIB FRACTURE

Date of diagnosis: S/C

Side affected: [ ] Right [X] Left [ ] Both

SECTION II: HISTORY OF MUSCLE INJURY

------------------------------------

a. Does the Veteran have a penetrating muscle injury, such as a gunshot or shell fragment wound?

[ ] Yes[X] No

b. Does the Veteran have a non-penetrating muscle injury (such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)?

[X] Yes[ ] No

c. Describe the history (including onset and course) of the Veteran's muscle

injury: (brief summary):

THIS EXAM IS FOR CURRENT STATUS OF S/C LEFT RIB FRACTURE. PATIENT SAYS HE GETS OCCASIONAL MILD PAIN IN LEFT RIB IF SITS TOO LONG BUT NO NEED OF MEDICINE.

d. Dominant hand

[X] Right[ ] Left[ ] Ambidextrous

SECTION III: LOCATION OF MUSCLE INJURY

--------------------------------------

1. Shoulder girdle and arm

--------------------------

Does the Veteran now have or has he/she ever had an injury to a muscle group of the shoulder girdle or arm?

[ ] Yes[X] No

2. Forearm and hand

-------------------

Does the Veteran now have or has he/she ever had an injury to a muscle group of the forearm or hand?

[ ] Yes[X] No

3. Foot and leg

---------------

Does the Veteran now have or has he/she ever had an injury to a muscle group of the foot or leg?

[ ] Yes[X] No

4. Pelvic girdle and thigh

--------------------------

Does the Veteran now have or has he/she ever had an injury to a muscle group of the pelvic girdle or thigh?

[ ] Yes[X] No

5. Torso and neck

-----------------

Does the Veteran now have or has he/she ever had an injury to a muscle group in the torso and/or neck?

[ ] Yes[X] No

6. Additional conditions

------------------------

a. Does the Veteran have a history of rupture of the diaphragm with herniation?

[ ] Yes[X] No

b. Does the Veteran have a history of an extensive muscle hernia of any muscle, without other injury to the muscle?

[ ] Yes[X] No

c. Does the Veteran have a history of injury to the facial muscles?

[ ] Yes[X] No

SECTION IV: MUSCLE INJURY EXAM

------------------------------

1. Scar, fascia and muscle findings

-----------------------------------

a. Does the Veteran have any scar(s) associated with a muscle injury?

[ ] Yes[X] No

b. Does the Veteran have any known fascial defects or evidence of fascial defects associated with any muscle injuries?

[ ] Yes[X] No

c. Does the Veteran's muscle injury(ies) affect muscle substance or function?

[ ] Yes[X] No

2. Cardinal signs and symptoms of muscle disability

---------------------------------------------------

Does the Veteran have any of the following signs and/or symptoms attributable to any muscle injuries?

[X] Yes[ ] No

If yes, check all that apply, and indicate side affected, muscle group and frequency/severity.

[X] Fatigue-pain

If checked, indicate side affected: [ ] Right [X] Left [ ] Both

Indicate muscle group(s) affected (I-XXIII) if possible: LEFT RIBS

Indicate frequency/severity:

[X] Occasional[ ] Consistent[ ] Consistent at a more severe level

3. Muscle strength testing

--------------------------

Rate strength according to the following scale:

0/5 No muscle movement

1/5 Visible muscle movement, but no joint movement

2/5 No movement against gravity

3/5 No movement against resistance

4/5 Less than normal strength

5/5 Normal strength

Shoulder abduction (Group III)