Specific Impairments

ANOXIC ENCEPHALOPATHY
(Examples: Anesthesia accents, asphyxiation, cerebral palsy/birth injury, mental retardation.)

Current neurological status:

• Coma (level and duration)
• Mobility
• Seizures (type, frequency and severity)
• Anatomical damage

Indication of current level of mental functions:

• IQ measurement - Special education or mainstream education
• Ability to handle activities of daily living (ADL's,)
• Cognitive impairments - Include the names of the tests that were performed to arrive at the current status
• Degree of mental retardation, if any

BURNS

• Chemical or thermal?
• % of body surface burned?
• Severity of burns
• Prognosis for future management
• Respiratory involvement?

CANCER

• Report of original diagnosis
• Treatment
• Recurrences
• Current pathology report and Clinical stage
  

ENDOCRINE/METABOLIC DISORDERS

• Diabetes - type duration, age at onset, treatment, evidence of control, complications, retinopathy, neuropathy, amputations
• Pituitary disorders - diagnosis, treatment, complications
• Adrenal disorders - diagnosis, treatment complications

GASTROINTESTINAL DISORDERS

• Type - ulcerative colitis/proctitis, Crohn's disease, peptic ulcer disease, liver disease, and cirrhosis
• Treatment (surgeries, medication)

GENITOURINARY

• End stage renal disease (ESRD)
• Treatment regimen (e.g., dialysis, kidney transplant)
• Status- If post-transplant, need a recent report of rejection factors, if any.
  

• Extent of the original injury: open or closed head injury, skull fracture, hydrocephalus, vp shunt, hematoma, surgical procedures
• Brain stem injury - mid-line shift
• Current neurological status: coma seizures, etc.
• Description of residuals
  

HEART AND/OR CIRCULATORY DISEASE

• Type
• History of the condition
• Results of testing
• If history of myocardial Infarction, type and number of attacks
• Treatments and patient response
• For Bypass surgery (CABG) number of vessels involved
  

MENTAL DISORDERS
Neurosis, psychosis, organic brain disease

• Symptoms
• Treatment
• Suicide attempt/gesture

MISCELLANEOUS

• Organ transplants - any chronic rejection factors? Subsequent hospitalization, if any?
• AIDS/HIV+ - include symptoms, if any and T-4 (helper) cell count.
  

NEUROLOGICAL DISORDERS

• Brain and spinal cord tumors (gliomas, meningiomas, acoustic neuromas)
• Treatment/surgery – Include pathology report

Degree of recovery:

• Central nervous system disorders (e.g., Amyotrophic Lateral Sclerosis, Friedreich's Ataxia, Huntington's Chorea)
• Seizure disorder/Epilepsy
• Type and frequency of seizures

Date of last seizure:

• Treatment and degree of control
• Multiple sclerosis - single or multiple attacks
• Muscular Dystrophies - exact type and course
  Parkinson's disease

PULMONARY (RESPIRATORY) DISEASE

• Type - chronic obstructive pulmonary disease (COPD), emphysema, interstitial lung disease (ILD), asbestosis, etc.
• Original and current medical assessment/diagnosis - include reports from pulmonary function tests and arterial blood gases.
• Treatments and patient response
• Degree of impairment
  

SPINAL CORD INJURY
Paraplegia, quadriplegia, paresis

Extent of the original injury:

• Level of injury
• Current neurological status
• Urinary tract complications
• Response to rehabilitation

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