TN 22 (09-20)

DI 22510.111 Adult Consultative Examination (CE) Report Content Guidelines for Neurological Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with neurological disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

A. General guidelines for CE report content for adult neurological disorders

The CE report guidelines for adult neurological disorders in this section are in addition to the general CE report content guidelines in DI 22510.100.

B. Report content specific to neurological disorders

The CE provider will use the specific requirements below to complete the CE report for a neurological disorder.

1. Current medical history

The CE provider will describe and discuss, as appropriate:

a. Cognitive impairment;

b. Motor weakness;

c. Sensory abnormalities;

d. Problems with speech;

e. Problems with swallowing;

f. Problems with voiding and defecation;

g. Complete description of seizures including type and severity, auras, behavior prior to seizure, diurnal or nocturnal, frequency per month during the past year, duration of episodes, postictal phenomena, and date of last three seizures;

h. Cooperation with taking medication as prescribed and response to treatment;

i. Blood levels, if available;

j. Dates and results of relevant electrodiagnostic studies, such as EMG, NCV, evoked potentials, or EEG; and

k. Headaches, including known triggers, frequency, length, and response to treatment.

2. Physical examination

The CE provider will describe and discuss, as appropriate:

a. Any apparent abnormalities in gait:

1. Gait (including timed walking speed, when appropriate), or

2. Need for any type of assistive device and the reason such device is needed.

b. Mobility (including hand dominance) – ability to:

1. Use the upper extremities effectively for gross and fine movements;

2. Get up from a seated position and stand;

3. Walk with and without assistance;

4. Get on and off the examination table;

5. Tandem walk; and

6. Walk on heels and toes.

c. Coordination – abnormal movements, especially tremors and incoordination

d. Motor function:

1. Strength – 0-5/5 (MRC scale) or dynamometer, when appropriate;

2. Atrophy or flaccidity;

3. Spasticity;

4. Rigidity;

5. Limitation of movement;

6. Fatigability of extremities; and

7. Reflexes – deep tendon and superficial.

e. Myasthenia gravis or cases in which fatigue is alleged: Test for ability to fatigue the claimant by exercise (for example, ptosis develops after 1 minute of attempted up gaze or strength declines from 5/5 at rest to 2/5 after 10 minutes of exercise of a particular muscle).

f. Cranial nerve functions:

1. Visual acuity and confrontation visual fields;

2. Pupillary response to light and accommodation;

3. Examination of extraocular movements or presence of nystagmus;

4. Facial sensation including corneal reflex and masseter strength and bulk;

5. Facial muscle strength and symmetry;

6. Hearing test; and

7. Other functions, as appropriate, such as gag reflex, neck muscle strength, ability to detect odors, and tongue movement (strength or atrophy).

g. Sensory function:

1. Pattern – anatomic or non-anatomic; and

2. Characteristics of any pain and relationship to underlying disorder.

h. Mental status examination:

1. Orientation;

2. Memory;

3. Calculation;

4. Insight;

5. General understanding;

6. Fund of knowledge; and

7. Mood and behavior during examination.

i. Speech and language functioning:

1. Intelligibility and fluency;

2. Aphasia including ability to comprehend language or produce language either spoken or written;

3. Dysarthria;

4. Stuttering; and

5. Involuntary vocalizations.

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DI 22510.111 - Adult Consultative Examination (CE) Report Content Guidelines for Neurological Disorders - 09/25/2020
Batch run: 09/25/2020