DVBCWPN1 ;ALB/CMM PERIPHERAL NERVES WKS TEXT - 1 ; 6 MARCH 1997 ;;2.7;AMIE;**12**;Apr 10, 1995 ; ; TXT ; ;;A. Review of Medical Records: ;; ;; ;; ;;B. Medical History (Subjective Complaints): ;; ;; Comment on: ;; 1. Onset and course - If flare-ups exist, describe precipitating ;; factors, aggravating factors, alleviating factors, alleviating ;; medications, frequency, severity, duration, and whether the ;; flare-ups include pain, weakness, fatigue, or functional loss. ;; ;; ;; 2. Current treatment, response, and side effects. ;; ;; ;; 3. Paresthesias, dysesthesias, other sensory abnormalities. ;; ;; ;; 4. Describe extent to which condition interferes with daily activity. ;; ;; ;; 5. Specify nerves involved. ;; ;; ;;C. Physical Examination (Objective Findings): ;; ;; Address reach of the following and fully describe current findings: ;; 1. If the disability is the result of brain disease or injury, ;; spinal cord disease or injury, cervical disc disease, or ;; trauma to the nerve roots themselves: ;; a. Report sensory and motor impairment by reference to the ;; distribution of the affected groups as paralysis, ;; neuritis, or neuralgia. ;; ;; ;; b. Report each affected extremity separately. ;; ;; ;; 2. If disability is NOT from the above: ;; a. Identify the specific major nerve involved, localize the ;; lesion and describe specific impairment of motor and ;; sensory function, fine motor control, etc. ;; ;; ;; b. Characterize as paralysis, neuritis, or neuralgia, and ;; indicate whether any muscle wasting or atrophy represents ;; direct effect of nerve damage or merely disuse. ;; ;; ;; c. Report each affected extremity separately. ;; ;; ;; 3. For each joint that is affected: ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range ;; of motion, including movement against gravity and against ;; strong resistance. ;; ;; ;; b. If the joint is painful on motion, state at what point in ;; the range of motion pain begins and ends. ;; ;; ;; c. State to what extent, if any, the range of motion or ;; function is ADDITIONALLY LIMITED by pain, fatigue, weakness, ;; or lack of endurance. If more than one of these is present, ;; state, if possible, which has the major functional impact. ;; ;; ;;D. Diagnostic and Clinical Tests: ;; ;; 1. Include results of all diagnostic and clinical tests conducted ;; in the examination report. ;; ;; ;;E. Diagnosis: ;; ;; 1. State etiology. ;; ;; ;;Signature: Date: ;;END