source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWFW1.m@ 1132

DVBCWFW1 ;ALB/CMM FEET 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.  Pain, weakness, stiffness, swelling, heat, redness, 
 ;;        fatigability, lack of endurance, etc.  Describe symptoms at 
 ;;        rest and on standing and walking.
 ;;
 ;;
 ;;    2.  Treatment - type, dose, frequency, response, side effects.
 ;;
 ;;
 ;;    3.  If there are periods of flare-up of joint disease:
 ;;        a.  State their severity, frequency, and duration.
 ;;
 ;;
 ;;        b.  Name the precipitating and alleviating factors.
 ;;
 ;;
 ;;        c.  Estimate to what extent, if any, they result in additional
 ;;            limitation of motion or functional impairment during the 
 ;;            flare-up.
 ;;
 ;;
 ;;    4.  Describe whether crutches, brace, cane, corrective shoes, 
 ;;        etc., are needed.
 ;;
 ;;
 ;;    5.  Describe details of any surgery or injury.
 ;;
 ;;
 ;;    6.  Describe corrective shoes, shoe inserts, or braces used and 
 ;;        their efficacy.
 ;;
 ;;
 ;;    7.  Describe effects of the condition(s) on the veteran's usual 
 ;;        occupation and daily activities.
 ;;
 ;;TOF
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following as appropriate to the condition 
 ;;    being examined and fully describe current findings:  A DETAILED 
 ;;    ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED.
 ;;
 ;;    1.  Describe each foot separately.  For nomenclature of toes use:
 ;;        great toe, second, third, fourth, and fifth.  The functional 
 ;;        loss should be related to the anatomical condition.
 ;;
 ;;
 ;;    2.  Using a goniometer, measure the PASSIVE and ACTIVE range of 
 ;;        motion, including movement against gravity and against strong
 ;;        resistance.
 ;;
 ;;
 ;;    3.  If the joint is painful on motion, state at what point in the
 ;;        range of motion pain begins and ends.
 ;;
 ;;
 ;;    4.  State to what extent (if any) and in which degrees (if possible) 
 ;;        the range of motion or function is ADDITIONALLY LIMITED by 
 ;;        pain, fatigue, weakness, or lack of endurance following 
 ;;        repetitive use or during flare-ups.  If more than one of these
 ;;        is present, state, if possible, which has the major functional
 ;;        impact.
 ;;
 ;;
 ;;    5.  Describe objective evidence of painful motion, edema, 
 ;;        instability, weakness, tenderness, etc.
 ;;
 ;;
 ;;    6.  Describe gait and functional limitations on standing and walking.
 ;;
 ;;
 ;;    7.  Describe any callosities, breakdown, or unusual shoe wear 
 ;;        pattern that would indicate abnormal weight bearing.
 ;;
 ;;
 ;;    8.  Describe any skin and vascular changes.
 ;;
 ;;
 ;;    9.  Posture on standing, squatting, supination, pronation, and 
 ;;        rising on toes and heels.
 ;;
 ;;
 ;;   10.  Describe hammertoes, high arch, clawfoot, or other deformity -
 ;;        actively or passively correctable?
 ;;
 ;;
 ;;   11.  For flatfoot
 ;;        a.  Describe weight bearing and non-weight bearing alignment 
 ;;            of the Achilles tendon.
 ;;
 ;;
 ;;        b.  Describe whether the Achilles tendon alignment can be 
 ;;            corrected by manipulation and whether there is pain on 
 ;;            manipulation.
 ;;
 ;;
 ;;        c.  Describe degrees of valgus and whether correctable by 
 ;;            manipulation.
 ;;
 ;;
 ;;        d.  Describe extent of forefoot and midfoot malalignment and 
 ;;            whether correctable by manipulation.
 ;;
 ;;
 ;;   12.  For hallux valgus, describe angulation and dorsiflexion at 
 ;;        first metatarsal phalangeal joints.  
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    Comment on:
 ;;    1.  X-rays for flatfoot and clawfoot - weight bearing AP and 
 ;;        lateral views and non-weight bearing AP, lateral, and oblique
 ;;        views.
 ;;    2.  For other conditions, AP, lateral, and oblique of entire foot,
 ;;        as applicable.
 ;;    3.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END