source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWB1.m@ 1088

DVBCWB1 ;ALB/CMM BONES 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.  Describe details of any injury, episodes of osteomyelitis, or
 ;;        surgery.
 ;;
 ;;
 ;;    2.  Symptoms of pain, weakness, stiffness, swelling, heat, redness,
 ;;        drainage, instability or giving way, "locking," abnormal motion, etc.
 ;;
 ;;
 ;;    3.  Treatment:  medication type, dose, frequency, response, and 
 ;;        side effects; other treatment.
 ;;
 ;;
 ;;    4.  If there are periods of flare-up of bone disease:
 ;;        a.  State their severity, frequency, and duration.
 ;;
 ;;
 ;;        b.  Name the precipitating and alleviating factors.
 ;;
 ;;
 ;;        c.  Estimate to what extent, if any, they affect functional 
 ;;            impairment during the flare-up.
 ;;
 ;;
 ;;
 ;;    5.  Is there current active infection?  If not, when was the last
 ;;        active infection?  How was it determined?
 ;;
 ;;
 ;;    6.  Describe whether crutches, brace, cane, corrective shoes, etc.,
 ;;        are needed.
 ;;
 ;;
 ;;    7.  Are there constitutional symptoms of bone disease?
 ;;
 ;;
 ;;    8.  Describe the effects of the condition on the veteran's usual 
 ;;        occupation and daily activities.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;     Address each of the following as appropriate to the disability 
 ;;     being examined and fully describe current findings:
 ;;
 ;;     1.  Describe objective evidence of deformity, angulation, false 
 ;;         motion, shortening, intra-articular involvement, etc.
 ;;
 ;;
 ;;     2.  Malunion, nonunion, any loose motion, false joint.
 ;;
 ;;
 ;;     3.  Tenderness, drainage, edema, painful motion, weakness, redness, heat.
 ;;
 ;;
 ;;     4.  For weight bearing joints (hip, knee, ankle), describe gait
 ;;         and functional limitations on standing and walking.  Describe
 ;;         any callosities, breakdown, or unusual shoe wear pattern that
 ;;         would indicate abnormal weight bearing.
 ;;
 ;;
 ;;     5.  If ankylosis is present, describe the position of the bones 
 ;;         of the joint in relationship to one another (in degrees of 
 ;;         flexion, external rotation, etc.), and state whether the 
 ;;         ankylosis is stable and pain free.
 ;;
 ;;
 ;;     6.  With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED 
 ;;         JOINT IS REQUIRED.  
 ;;     NOTE:  See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and 
 ;;     Ankle for normal range of motion of those joints.
 ;;
 ;;
 ;;         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.
 ;;
 ;;
 ;;     7.  If shortening of the leg may be present, measure the leg 
 ;;         length from the anterior superior iliac spine to the medial 
 ;;         malleolus.
 ;;
 ;;
 ;;     8.  Are there constitutional signs of bone disease - anemia, 
 ;;         weight loss, fever, debility, amyloid liver, etc.?
 ;;
 ;;
 ;;
 ;;D.   Diagnostic and Clinical Tests:
 ;;
 ;;     1.  As indicated:  X-rays, including special views or weight 
 ;;         bearing films, MRI, arthrogram, diagnostic arthroscopy.  
 ;;     NOTE:  The diagnosis of degenerative arthritis or post-traumatic
 ;;     arthritis of a joint requires X-ray confirmation.  Once the 
 ;;     diagnosis has been confirmed in a joint, further X-rays of that 
 ;;     joint are not required.
 ;;     2.  For osteomyelitis, state whether there is an involucrum, 
 ;;         sequestrum, or draining sinus.
 ;;     3.  Include results of all diagnostic and clinical tests 
 ;;         conducted in the examination report.
 ;;
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;
 ;;Signature:                                   Date:
 ;;END