source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWHT1.m@ 1726

DVBCWHT1 ;ALB/CMM HAND, THUMB, FINGERS 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.  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.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following as appropriate to the condition being 
 ;;    examined and full describe current findings:
 ;;    1.  Anatomical defects.
 ;;
 ;;
 ;;    2.  Functional defects (motion of thumb and fingers should be 
 ;;        described as to how near, in inches, the tip of thumb can 
 ;;        approximate the fingers, or how near the tips of fingers can 
 ;;        approximate the median transverse fold of the palm.
 ;;
 ;;
 ;;    3.  Grasping objects (strength and dexterity).
 ;;
 ;;
 ;;The hand should be evaluated as a unit intricately adapted for grasping, 
 ;;pushing, pulling, twisting, probing, writing, touching, and expression.  
 ;;Do not designate fingers numerically; use thumb, index, middle (or 
 ;;long), ring, and little.  Specify which hand is involved and state 
 ;;whether the individual is right- or left-handed.  Designate the joints
 ;;as wrist, MP (metacarpophalangeal), PIP (proximal interphalangeal), or
 ;;DIP (distal interphalangeal).  Designate phalanges as proximal, middle
 ;;or distal.
 ;;
 ;;TOF
 ;;    4.  A detailed assessment of each affected joint is required.
 ;;        a.  Using a goniometer, measure the PASSIVE and ACTIVE range 
 ;;            of motion, including movement against gravity and against
 ;;            strong resistance.
 ;;
 ;;
 ;;        b.  State to what extent (if any) and in which degrees (if 
 ;;            possible) the range of motion or joint 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.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Include results of all diagnostic and clinical tests conducte
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END