source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWJW1.m@ 794

DVBCWJW1 ;ALB/CMM JOINTS 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 and redness, 
 ;;        instability or giving way, "locking," fatigability, lack of 
 ;;        endurance, etc.
 ;;
 ;;
 ;;    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 any episodes of dislocation or recurrent subluxation.
 ;;
 ;;
 ;;    7.  For inflammatory arthritis, describe any constitutional symptoms.
 ;;
 ;;
 ;;    8.  Describe the effects of the condition on the veteran's usual 
 ;;        occupation and daily activities.
 ;;
 ;;TOF
 ;;    9.  For upper extremity, state which is dominant and means used to
 ;;        identify dominant extremity.
 ;;
 ;;
 ;;   10.  If there is a prosthesis, provide date of prosthetic implant
 ;;        and describe any complaint of pain, weakness, or limitation of
 ;;        motion.  State whether crutches, brace, etc., are needed.
 ;;
 ;;
 ;;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, INCLUDING JOINTS 
 ;;    WITH PROSTHESES.
 ;;    1.  Using a goniometer, measure the PASSIVE and ACTIVE range of 
 ;;        motion, including movement against gravity and against strong
 ;;        resistance.  Provide range of motion in degrees.
 ;;
 ;;
 ;;    2.  If the joint is painful on motion, state at what point in the
 ;;        range of motion pain begins and ends.  
 ;;
 ;;
 ;;    3.  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.
 ;;
 ;;
 ;;    4.  Describe objective evidence of painful motion, edema, effusion, 
 ;;        instability, weakness, tenderness, redness, heat, abnormal 
 ;;        movement, guarding of movement, etc.
 ;;
 ;;
 ;;    5.  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.
 ;;
 ;;
 ;;    6.  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.
 ;;
 ;;
 ;;   7.  If indicated, measure the leg length from the anterior superior
 ;;       iliac spine to the medial malleolus.
 ;;
 ;;
 ;;   8.  For INFLAMMATORY ARTHRITIS, describe any constitutional signs.
 ;;
 ;;
 ;;   9.  Describe range of motion with prosthesis in same detail as 
 ;;       described above for non-prosthetic joints.
 ;;
 ;;
 ;;D.  Normal Range of Motion:  All joint Range of Motion measurements 
 ;;must be made using a GONIOMETER.  Show each measured range of motion 
 ;;separately rather than as a continuum.  For example, if the veteran 
 ;;lacks 10 degrees of full knee extension and has normal flexion, show 
 ;;the range of motion as extension to minus 10 degrees (or lacks 10 
 ;;degrees of extension) and flexion 0 to 140 degrees.  
 ;;
 ;;    1.  Hip range of motion:  (Movement of femur as it rotates in the
 ;;        acetabulum.)
 ;;
 ;;        a.  Normal range of motion, using the anatomical position as 
 ;;            zero degrees.  
 ;;            Flexion = 0 to 125 degrees (To gain a true picture of hip
 ;;            flexion, i.e., movement between the pelvis and femur in 
 ;;            the hip joint, the opposite thigh should be extended to 
 ;;            minimize motion between the pelvis and spine.)
 ;;            Extension = 0 to 30 degrees.
 ;;            Adduction = 0 to 25 degrees.
 ;;            Abduction = 0 to 45 degrees.
 ;;            External rotation = 0 to 60 degrees.
 ;;            Internal rotation = 0 to 40 degrees.
 ;;
 ;;
 ;;    2.  Knee range of motion:
 ;;        a.  Normal range of motion, using the anatomical position as 
 ;;            zero degrees.
 ;;            Flexion = 0 to 140 degrees.
 ;;            Extension - zero degrees = full extension.  Show loss of 
 ;;            extension by describing the degrees in which extension is
 ;;            not possible.  (e.g., Show range of motion as extension to
 ;;            minus 10 degrees and flexion 0 to 140 degrees when full
 ;;            extension is limited by 10 degrees and full flexion is 
 ;;            possible.)
 ;;
 ;;TOF
 ;;        b.  Stability.
 ;;            Medial and Lateral Collateral Ligaments:
 ;;               Varus/valgus in neutral and in 30 degrees of flexion -
 ;;               normal is no motion.
 ;;            Anterior and Posterior Cruciate Ligaments:
 ;;               Anterior/posterior in 30 degrees of flexion with foot 
 ;;               stabilized - normal is less than 5 mm. of motion (1/4 
 ;;               inch - Lachman's test) or in 90 degrees of flexion with
 ;;               foot stabilized - normal is less than 5mm. of motion 
 ;;               (1/4 inch - anterior and posterior drawer test).
 ;;            Medial and Lateral Meniscus:  Perform McMurray's test.
 ;;
 ;;
 ;;    3.  Ankle range of motion:
 ;;        a.  Neutral position is with foot at 90 degrees to ankle.  
 ;;            From that position, dorsiflexion is 0 to 20 degrees; 
 ;;            plantar flexion is 0 to 45 degrees.
 ;;
 ;;
 ;;        b.  Describe any varus or valgus angulation of the os calcis 
 ;;            in relationship to the long axis of the tibia and fibula.
 ;;
 ;;
 ;;    4.  Shoulder, elbow, forearm, and wrist range of motion:
 ;;        a.  Normal range of motion is measured with zero degrees the 
 ;;            anatomical position except for 2 situations:
 ;;
 ;;            (1)  Supination and pronation of the forearm is measured 
 ;;                 with the arm against the body, the elbow flexed to 90
 ;;                 degrees, and the forearm in mid position (zero degrees) 
 ;;                 between supination and pronation.
 ;;
 ;;
 ;;            (2)  Shoulder rotation is measured with the arm abducted 
 ;;                 to 90 degrees, the elbow flexed to 90 degrees, and 
 ;;                 the forearm reflecting the midpoint (zero degrees) 
 ;;                 between internal and external rotation of the shoulder.
 ;;
 ;;
 ;;        b.  Shoulder forward flexion = zero to 180 degrees.
 ;;
 ;;
 ;;        c.  Shoulder abduction = zero to 180 degrees.
 ;;
 ;;
 ;;        d.  Shoulder external rotation = zero to 90 degrees.
 ;;
 ;;
 ;;        e.  Shoulder internal rotation = zero to 90 degrees.
 ;;
 ;;
 ;;        f.  Elbow flexion = zero to 145 degrees.
 ;;
 ;;
 ;;        g.  Forearm supination = zero to 85 degrees.
 ;;
 ;;
 ;;        h.  Forearm pronation = zero to 80 degrees.
 ;;
 ;;
 ;;        i.  Wrist dorsiflexion (extension) = zero to 70 degrees.
 ;;
 ;;
 ;;        j.  Wrist palmar flexion = zero to 80 degrees.
 ;;
 ;;
 ;;        k.  Wrist radial deviation = zero to 20 degrees.
 ;;
 ;;
 ;;        l.  Wrist ulnar deviation = zero to 45 degrees.
 ;;
 ;;
 ;;E.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  As indicated:  X-rays, including special views or weight 
 ;;        bearing films, MRI, arthrogram, diagnostic arthroscopy. 
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;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.
 ;;
 ;;
 ;;F.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END