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Microsoft word - letter 8.doc

November 24, 2009
To Whom It May Concern:
Jonathan is a 13-year-old boy with progressive muscular weakness due to Duchenne
Muscular Dystrophy (DMD). He is being followed by the Pediatric Neuromuscular
Center at “ABC” Rehab. His most recent evaluation was on 10/27/09. He presents with
weakness in all four limbs and is wheelchair bound. Jonathan has plantar flexion
contractures bilaterally and moderate hamstring tightness. He wears recently made
custom molded AFOs which he wears for about 2-3 hours per day when using a stander.
He is able to feed himself, brush his teeth, and perform upper body dressing
independently but requires assistance to perform lower body dressing. He is dependent
with transfers and has a Hoyer lift he uses at home. He relies on a power wheelchair for
mobility. He is no longer able to walk, despite the use of a walker and bilateral AFOs. He
is unable to manage a rolling walker, cane or other assistive devices due to his arm
weakness even with assistance from his caregivers. He has a back-up manual wheelchair,
however he now has difficulty self propel his manual wheelchair short distances at home
secondary to decreased endurance and strength. He has a paraprofessional throughout the
day in school but remains in the power wheelchair throughout the school day. He now
needs modifications to his current power wheelchair.
Jonathan is currently 56.7 inches and 141 lbs. he is currently using an Invacare Storm
TDX power wheelchair that he has had for 2.5 years which needs modifications and
adjustments to fit him properly and promote optimal alignment. Jonathan is wheelchair
bound and he uses it independently in school and outdoors. He received his power
wheelchair 2.5 years ago from RRT which is no longer in business. His weight has
increased since he’s been on Prednisone and his power wheelchair needs to be grown.
Upon evaluation, his chest strap is no longer long enough, the hip abductor pads are
pushing into the sides of his legs and his calves are pushing into the swing-away portion
of the footrests increasing his risk for pressure sores and injury. Jonathan was measures
and now requires a 20x22 wide chair. He currently sits in 15x15 size chair. Power tilt will
be added to his power wheelchair to assist with pressure relief and repositioning. He will
be getting a new chest strap and new headrest for when he goes into tilt. His footrests will
be adjusted for comfort once sitting. He will require a new back insert and cushion.
He has mobility limitations that impair his ability to participate in mobility related
activities of daily living (MRADL) that couldn’t be sufficiently and safely resolved by
the use of a cane or walker. Modifications made to his power wheelchair are requires for
Jonathan to use it in the home and community setting. The length of needs for these
modifications to his power wheelchair is for lifetime. He is currently using an Invacare
power wheelchair that he has had for 2.5 years which needs modifications and
adjustments to fit him properly and promote optimal alignment:
Invacare receivers for existing footrests: The receivers are requires so the footrests can
be attached to the top system.
BioDynamics Solid back insert, linear, with 1.5” foam with adjustable lateral trunk
supports:
A posterior positioning back is requires to correct and accommodate the
postural asymmetries of the thoracic and lumbar spice which result from muscle
weakness, poor motor control and impaired balance due to the diagnosis of DMD.
Adjustable lateral trunk supports are requires to prevent lateral flexion and to promote
proper seating alignment. They are requires because of Jonathan’s decreased trunk tone
and control. Removable lateral thoracic support brackets are required to allow removal of
the support pads for safe transfers, personal care, repositioning and functional activities.
Lower-level, less expensive backs won’t suffice and meet the requirements of Jonathan’s
positional needs.
BioDynamics positioning cushion to attach to seat pan, vinyl cover; with 3” growth
tall:
Jonathan is unable to carry out a functional weight shift due to his diagnosis of
DMD. He will be confined to his wheelchair fore more than 6 continuous hours on a
daily basis when at school. He has significant postural asymmetries due to his diagnosis
of DMD and is unable to perform an adequate weight shift secondary to his weakness. He
requires a seat cushion with sufficient pressure-relieving capabilities to maintain intact
skin integrity and to allow for functional sitting tolerance. This cushion provides the
proper combination of pressure relief and positional support necessary for him in his
power wheelchair. Lower-level, less expensive cushions won’t suffice and meet the
requirements of Jonathan’s positional needs.
1 pair hip guides; BioDynamics adjustable via back insert: This is required to prevent
Jonathan’s legs from abducting to a position wider than the wheelchair and will maintain
him in proper hip alignment while operating the wheelchair.
1 pair lateral knee supports BioDynamics, removable: This is required to prevent
Jonathan’s thighs from abducting to a position wider than the wheelchair and will
maintain him in proper alignment while operating the wheelchair. This will prevent his
lower extremities (calves) from resting on the swing-away function of the swing-away
leg rests and will prevent injury and pressure sores.
BioDynamics Chest Belt, Velcro across lateral supports with pad in center 8”x3”:
This type of belt is requires for safety when being transported in the school bus to/from
school. Also, it provides input to the anterior torso to maintain an upright position. The
belt will maintain proper positioning while seated in the wheelchair.
BioDynamics headrest with detachable hardware: A headrest is needed to support
Jonathan’s head in optimal position. He is unable to maintain an upright, middling head
and neck position due to muscle weakness, poor motor control and poor sitting balance.
Removable headrest brackets are required to allow removal of the support pads for safe
transfers, personal care, and repositioning and functional activities.
It is medically necessary for Jonathan to receive these modifications to his current power
wheelchair to support his needs to improve alignment, slow progression of further
deformity and provide total body comfort to increase sitting tolerance. He requires these
modifications to assist and support his needs in the home and community and to prevent
fatigue so he can actively participate. Jonathan has the functional ability to use his drive
controls and has adequate cognition, visual ability and judgment necessary to safely
operate his power wheelchair independently. He uses a standard joystick that must be
positioned functionally to operate the wheelchair independently. His home is already
wheelchair accessible and there is accessible transportation available to his family.
If Jonathan does not receive these modifications to his current power wheelchair, the
medical consequences include a loss of function, discomfort leading to reduced sitting
tolerance, increased pressure, and reduced participation and socialization. Anything you
can do to ensure that Jonathan receives this very necessary equipment would be greatly
appreciated. Please do not hesitate to contact us with questions or comments at 555-555-
5555.
Sincerely,
**Modification**

January 07, 2010
To Whom It May Concern:
I am writing to provide an addendum to Jonathan’s letter of justification for his power
wheelchair modifications:
1 pair lateral knee supports, BioDynamics, removable: This is required to prevent
Jonathan’s thighs from abducting to a position wider than the wheelchair and will
maintain him in proper alignment while operating the wheelchair. This will prevent his
lower extremities (calves) from resting on the swing-away function of the swing-away
leg rests and will prevent injury and pressure sores. They are requires to be removable for
safe and easy transfers. Without the quick release hardware, Jonathan would be at risk for
hitting the lateral knee supports when transferring in and out of the wheelchair making
him at risk for injury.
Sincerely,

Source: http://www.biodynamics.us/docs/lmn/CMN%20letter%20example%2008.pdf

Microsoft word - medizinerskriptum zahnersatzkunde.doc

Die Zahnersatzkunde gliedert sich in folgende Teilbereiche: • Parodontologie • Zahnersatzkunde (Prothetik und Restaurative Zahnheilkunde) festsitzender Zahnersatz (Kronen, Brücken, Goldgussfüllungen) abnehmbarer Zahnersatz (Total- und Teilprothesen) • Implantologie (Chirurgie und Prothetik) • Funktionslehre (Kiefergelenksdiagnostik und -therapie)

Microsoft word - 18 apr 2008

GLACIER COUNTY COMMISSIONERS REGULAR MEETING Friday, April 18, 2008 The Board of Glacier County Commissioners met at a regular meeting at 8:00 a.m. on Friday, April 18, 2008. Commissioners John Ray-not present late flight from Washington, D.C., Michael DesRosier-not present late flight from Washington, D.C.~Present @ 11:45 a.m., and Ron Rides At The Door was present. Clerk and Recorde

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