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

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1DVBCWJW1 ;ALB/CMM JOINTS WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Pain, weakness, stiffness, swelling, heat and redness,
14 ;; instability or giving way, "locking," fatigability, lack of
15 ;; endurance, etc.
16 ;;
17 ;;
18 ;; 2. Treatment - type, dose, frequency, response, side effects.
19 ;;
20 ;;
21 ;; 3. If there are periods of flare-up of joint disease:
22 ;; a. State their severity, frequency, and duration.
23 ;;
24 ;;
25 ;; b. Name the precipitating and alleviating factors.
26 ;;
27 ;;
28 ;; c. Estimate to what extent, if any, they result in additional
29 ;; limitation of motion or functional impairment during the
30 ;; flare-up.
31 ;;
32 ;;
33 ;; 4. Describe whether crutches, brace, cane, corrective shoes, etc.,
34 ;; are needed.
35 ;;
36 ;;
37 ;; 5. Describe details of any surgery or injury.
38 ;;
39 ;;
40 ;; 6. Describe any episodes of dislocation or recurrent subluxation.
41 ;;
42 ;;
43 ;; 7. For inflammatory arthritis, describe any constitutional symptoms.
44 ;;
45 ;;
46 ;; 8. Describe the effects of the condition on the veteran's usual
47 ;; occupation and daily activities.
48 ;;
49 ;;TOF
50 ;; 9. For upper extremity, state which is dominant and means used to
51 ;; identify dominant extremity.
52 ;;
53 ;;
54 ;; 10. If there is a prosthesis, provide date of prosthetic implant
55 ;; and describe any complaint of pain, weakness, or limitation of
56 ;; motion. State whether crutches, brace, etc., are needed.
57 ;;
58 ;;
59 ;;C. Physical Examination (Objective Findings):
60 ;;
61 ;; Address each of the following as appropriate to the condition
62 ;; being examined and fully describe current findings: A DETAILED
63 ;; ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED, INCLUDING JOINTS
64 ;; WITH PROSTHESES.
65 ;; 1. Using a goniometer, measure the PASSIVE and ACTIVE range of
66 ;; motion, including movement against gravity and against strong
67 ;; resistance. Provide range of motion in degrees.
68 ;;
69 ;;
70 ;; 2. If the joint is painful on motion, state at what point in the
71 ;; range of motion pain begins and ends.
72 ;;
73 ;;
74 ;; 3. State to what extent (if any) and in which degrees (if possible)
75 ;; the range of motion or joint function is ADDITIONALLY LIMITED
76 ;; by pain, fatigue, weakness, or lack of endurance following
77 ;; repetitive use or during flare-ups. If more than one of these
78 ;; is present, state, if possible, which has the major functional
79 ;; impact.
80 ;;
81 ;;
82 ;; 4. Describe objective evidence of painful motion, edema, effusion,
83 ;; instability, weakness, tenderness, redness, heat, abnormal
84 ;; movement, guarding of movement, etc.
85 ;;
86 ;;
87 ;; 5. For weight bearing joints (hip, knee, ankle), describe gait
88 ;; and functional limitations on standing and walking. Describe
89 ;; any callosities, breakdown, or unusual shoe wear pattern that
90 ;; would indicate abnormal weight bearing.
91 ;;
92 ;;
93 ;; 6. If ankylosis is present, describe the position of the bones of
94 ;; the joint in relationship to one another (in degrees of flexion,
95 ;; external rotation, etc.), and state whether the ankylosis is
96 ;; stable and pain free.
97 ;;
98 ;;
99 ;; 7. If indicated, measure the leg length from the anterior superior
100 ;; iliac spine to the medial malleolus.
101 ;;
102 ;;
103 ;; 8. For INFLAMMATORY ARTHRITIS, describe any constitutional signs.
104 ;;
105 ;;
106 ;; 9. Describe range of motion with prosthesis in same detail as
107 ;; described above for non-prosthetic joints.
108 ;;
109 ;;
110 ;;D. Normal Range of Motion: All joint Range of Motion measurements
111 ;;must be made using a GONIOMETER. Show each measured range of motion
112 ;;separately rather than as a continuum. For example, if the veteran
113 ;;lacks 10 degrees of full knee extension and has normal flexion, show
114 ;;the range of motion as extension to minus 10 degrees (or lacks 10
115 ;;degrees of extension) and flexion 0 to 140 degrees.
116 ;;
117 ;; 1. Hip range of motion: (Movement of femur as it rotates in the
118 ;; acetabulum.)
119 ;;
120 ;; a. Normal range of motion, using the anatomical position as
121 ;; zero degrees.
122 ;; Flexion = 0 to 125 degrees (To gain a true picture of hip
123 ;; flexion, i.e., movement between the pelvis and femur in
124 ;; the hip joint, the opposite thigh should be extended to
125 ;; minimize motion between the pelvis and spine.)
126 ;; Extension = 0 to 30 degrees.
127 ;; Adduction = 0 to 25 degrees.
128 ;; Abduction = 0 to 45 degrees.
129 ;; External rotation = 0 to 60 degrees.
130 ;; Internal rotation = 0 to 40 degrees.
131 ;;
132 ;;
133 ;; 2. Knee range of motion:
134 ;; a. Normal range of motion, using the anatomical position as
135 ;; zero degrees.
136 ;; Flexion = 0 to 140 degrees.
137 ;; Extension - zero degrees = full extension. Show loss of
138 ;; extension by describing the degrees in which extension is
139 ;; not possible. (e.g., Show range of motion as extension to
140 ;; minus 10 degrees and flexion 0 to 140 degrees when full
141 ;; extension is limited by 10 degrees and full flexion is
142 ;; possible.)
143 ;;
144 ;;TOF
145 ;; b. Stability.
146 ;; Medial and Lateral Collateral Ligaments:
147 ;; Varus/valgus in neutral and in 30 degrees of flexion -
148 ;; normal is no motion.
149 ;; Anterior and Posterior Cruciate Ligaments:
150 ;; Anterior/posterior in 30 degrees of flexion with foot
151 ;; stabilized - normal is less than 5 mm. of motion (1/4
152 ;; inch - Lachman's test) or in 90 degrees of flexion with
153 ;; foot stabilized - normal is less than 5mm. of motion
154 ;; (1/4 inch - anterior and posterior drawer test).
155 ;; Medial and Lateral Meniscus: Perform McMurray's test.
156 ;;
157 ;;
158 ;; 3. Ankle range of motion:
159 ;; a. Neutral position is with foot at 90 degrees to ankle.
160 ;; From that position, dorsiflexion is 0 to 20 degrees;
161 ;; plantar flexion is 0 to 45 degrees.
162 ;;
163 ;;
164 ;; b. Describe any varus or valgus angulation of the os calcis
165 ;; in relationship to the long axis of the tibia and fibula.
166 ;;
167 ;;
168 ;; 4. Shoulder, elbow, forearm, and wrist range of motion:
169 ;; a. Normal range of motion is measured with zero degrees the
170 ;; anatomical position except for 2 situations:
171 ;;
172 ;; (1) Supination and pronation of the forearm is measured
173 ;; with the arm against the body, the elbow flexed to 90
174 ;; degrees, and the forearm in mid position (zero degrees)
175 ;; between supination and pronation.
176 ;;
177 ;;
178 ;; (2) Shoulder rotation is measured with the arm abducted
179 ;; to 90 degrees, the elbow flexed to 90 degrees, and
180 ;; the forearm reflecting the midpoint (zero degrees)
181 ;; between internal and external rotation of the shoulder.
182 ;;
183 ;;
184 ;; b. Shoulder forward flexion = zero to 180 degrees.
185 ;;
186 ;;
187 ;; c. Shoulder abduction = zero to 180 degrees.
188 ;;
189 ;;
190 ;; d. Shoulder external rotation = zero to 90 degrees.
191 ;;
192 ;;
193 ;; e. Shoulder internal rotation = zero to 90 degrees.
194 ;;
195 ;;
196 ;; f. Elbow flexion = zero to 145 degrees.
197 ;;
198 ;;
199 ;; g. Forearm supination = zero to 85 degrees.
200 ;;
201 ;;
202 ;; h. Forearm pronation = zero to 80 degrees.
203 ;;
204 ;;
205 ;; i. Wrist dorsiflexion (extension) = zero to 70 degrees.
206 ;;
207 ;;
208 ;; j. Wrist palmar flexion = zero to 80 degrees.
209 ;;
210 ;;
211 ;; k. Wrist radial deviation = zero to 20 degrees.
212 ;;
213 ;;
214 ;; l. Wrist ulnar deviation = zero to 45 degrees.
215 ;;
216 ;;
217 ;;E. Diagnostic and Clinical Tests:
218 ;;
219 ;; 1. As indicated: X-rays, including special views or weight
220 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
221 ;; 2. Include results of all diagnostic and clinical tests conducted
222 ;; in the examination report.
223 ;;
224 ;;NOTE: The diagnosis of degenerative arthritis or post-traumatic
225 ;;arthritis of a joint requires X-ray confirmation. Once the diagnosis
226 ;;has been confirmed in a joint, further X-rays of that joint are not required.
227 ;;
228 ;;
229 ;;F. Diagnosis:
230 ;;
231 ;;
232 ;;Signature: Date:
233 ;;END
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