source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWJW5.m@ 1607

Last change on this file since 1607 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version

File size: 9.2 KB
Line 
1DVBCWJW5 ;ALB/RLC JOINTS WKS TEXT - 1 ; 7 APRIL 2005
2 ;;2.7;AMIE;**94**;FEB 17, 2004
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;;
14 ;; 1. Pain, weakness, stiffness, swelling, heat and redness,
15 ;; instability or giving way, "locking," fatigability, lack of
16 ;; endurance, etc.
17 ;; 2. Treatment - type, dose, frequency, response, side effects.
18 ;; 3. If there are periods of flare-up of joint disease:
19 ;;
20 ;; a. State their severity, frequency, and duration.
21 ;; b. Name the precipitating and alleviating factors.
22 ;; c. State to what extent, if any, per veteran, they
23 ;; result in additional limitation of motion or
24 ;; functional impairment during the flare-up.
25 ;;
26 ;; 4. Describe whether crutches, brace, cane, corrective shoes,
27 ;; etc., are needed.
28 ;; 5. Describe details of any surgery or injury.
29 ;; 6. Describe any episodes of dislocation or recurrent subluxation.
30 ;; 7. For inflammatory arthritis, describe any constitutional
31 ;; symptoms.
32 ;; 8. Describe the effects of the condition on the veteran's usual
33 ;; occupation and daily activities.
34 ;; 9. Dominance of extremity and means used to identify
35 ;; dominant extremity.
36 ;; 10. If there is a prosthesis, provide date of prosthetic implant
37 ;; and describe any complaint of pain, weakness, or limitation
38 ;; of motion. State whether crutches, brace, etc., are needed.
39 ;;
40 ;;
41 ;;C. Physical Examination (Objective Findings):
42 ;;
43 ;; Address each of the following as appropriate to the condition
44 ;; being examined and fully describe current findings: A DETAILED
45 ;; ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED, INCLUDING JOINTS
46 ;; WITH PROSTHESES.
47 ;;
48 ;; 1. Using a goniometer, measure the PASSIVE and ACTIVE range of
49 ;; motion, including movement against gravity and against strong
50 ;; resistance. Provide range of motion in degrees.
51 ;; 2. If the joint is painful on motion, state at what point in the
52 ;; range of motion pain begins and ends.
53 ;; 3. Describe presence or absence of: pain (including pain on repeated
54 ;; use); fatigue; weakness; lack of endurance; and incoordination.
55 ;; 4. Describe objective evidence of painful motion, edema,
56 ;; effusion, instability, weakness, tenderness, redness, heat,
57 ;; abnormal movement, guarding of movement, etc.
58 ;; 5. For weight bearing joints (hip, knee, ankle), describe gait
59 ;; and functional limitations on standing and walking. Describe
60 ;; any callosities, breakdown, or unusual shoe wear pattern that
61 ;; would indicate abnormal weight bearing.
62 ;; 6. If ankylosis is present, describe the position of the bones of
63 ;; the joint in relationship to one another (in degrees of flexion,
64 ;; external rotation, etc.), and state whether the ankylosis is
65 ;; stable and pain free.
66 ;; 7. If indicated, measure the leg length from the anterior
67 ;; superior iliac spine to the medial malleolus.
68 ;; 8. For INFLAMMATORY ARTHRITIS, describe any constitutional signs.
69 ;; 9. Describe range of motion with prosthesis in same detail as
70 ;; described above for non-prosthetic joints.
71 ;;
72 ;;
73 ;;D. Normal Range of Motion: All joint Range of Motion measurements
74 ;;must be made using a goniometer. Show each measured range of motion
75 ;;separately rather than as a continuum. For example, if the veteran
76 ;;lacks 10 degrees of full knee extension and has normal flexion, show
77 ;;the range of motion as extension to minus 10 degrees (or lacks 10
78 ;;degrees of extension) and flexion 0 to 140 degrees.
79 ;;
80 ;; 1. Hip range of motion: (Movement of femur as it rotates in the
81 ;; acetabulum.)
82 ;;
83 ;; a. Normal range of motion, using the anatomical
84 ;; position as zero degrees.
85 ;;
86 ;; Flexion = 0 to 125 degrees (To gain a true picture of hip
87 ;; flexion, i.e., movement between the pelvis and femur in
88 ;; the hip joint, the opposite thigh should be extended to
89 ;; minimize motion between the pelvis and spine.)
90 ;;
91 ;; Extension = 0 to 30 degrees.
92 ;;
93 ;; Adduction = 0 to 25 degrees.
94 ;;
95 ;; Abduction = 0 to 45 degrees.
96 ;;
97 ;; External rotation = 0 to 60 degrees.
98 ;;
99 ;; Internal rotation = 0 to 40 degrees.
100 ;;
101 ;;
102 ;; 2. Knee range of motion:
103 ;;
104 ;; a. Normal range of motion, using the anatomical
105 ;; position as zero degrees.
106 ;;
107 ;; Flexion = 0 to 140 degrees.
108 ;;
109 ;; Extension - zero degrees = full extension. Show loss of
110 ;; extension by describing the degrees in which extension is
111 ;; not possible. (e.g., Show range of motion as extension to
112 ;; minus 10 degrees and flexion 0 to 140 degrees when full
113 ;; extension is limited by 10 degrees and full flexion is
114 ;; possible.)
115 ;;
116 ;; b. Stability.
117 ;;
118 ;; Medial and Lateral Collateral Ligaments:
119 ;; Varus/valgus in neutral and in 30 degrees of flexion -
120 ;; normal is no motion.
121 ;;
122 ;; Anterior and Posterior Cruciate Ligaments:
123 ;; Anterior/posterior in 30 degrees of flexion with
124 ;; foot stabilized - normal is less than 5 mm. of motion
125 ;; (1/4 inch - Lachman's test) or in 90 degrees of flexion
126 ;; with foot stabilized - normal is less than 5mm. of motion
127 ;; (1/4 inch - anterior and posterior drawer test).
128 ;;
129 ;; Medial and Lateral Meniscus: Perform McMurray's test.
130 ;;
131 ;;
132 ;; 3. Ankle range of motion:
133 ;;
134 ;; a. Neutral position is with foot at 90 degrees to
135 ;; ankle. From that position, dorsiflexion is 0 to 20
136 ;; degrees; plantar flexion is 0 to 45 degrees.
137 ;; b. Describe any varus or valgus angulation of the
138 ;; os calcis in relationship to the long axis of the
139 ;; tibia and fibula.
140 ;;
141 ;;
142 ;; 4. Shoulder, elbow, forearm, and wrist range of motion:
143 ;;
144 ;; a. Normal range of motion is measured with zero degrees the
145 ;; anatomical position except for 2 situations:
146 ;;
147 ;; i. Supination and pronation of the
148 ;; forearm is measured with the arm
149 ;; against the body, the elbow
150 ;; flexed to 90 degrees, and the
151 ;; forearm in mid position (zero
152 ;; degrees) between supination and
153 ;; pronation.
154 ;; ii. Shoulder rotation is measured
155 ;; with the arm abducted to 90
156 ;; degrees, the elbow flexed to 90
157 ;; degrees, and the forearm
158 ;; reflecting the midpoint (zero
159 ;; degrees) between internal and
160 ;; external rotation of the shoulder.
161 ;;
162 ;; b. Shoulder forward flexion = zero to 180
163 ;; degrees.
164 ;; c. Shoulder abduction = zero to 180 degrees.
165 ;; d. Shoulder external rotation = zero to 90
166 ;; degrees.
167 ;; e. Shoulder internal rotation = zero to 90
168 ;; degrees.
169 ;; f. Elbow flexion = zero to 145 degrees.
170 ;; g. Forearm supination = zero to 85 degrees.
171 ;; h. Forearm pronation = zero to 80 degrees.
172 ;; i. Wrist dorsiflexion (extension) = zero to 70
173 ;; degrees.
174 ;; j. Wrist palmar flexion = zero to 80 degrees.
175 ;; k. Wrist radial deviation = zero to 20 degrees.
176 ;; l. Wrist ulnar deviation = zero to 45 degrees.
177 ;;
178 ;;
179 ;;E. Diagnostic and Clinical Tests:
180 ;;
181 ;; 1. As indicated: X-rays, including special views or weight
182 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
183 ;; NOTE: The diagnosis of degenerative arthritis or post-
184 ;; traumatic arthritis of a joint requires X-ray confirmation. Once
185 ;; the diagnosis has been confirmed in a joint, further X-rays of
186 ;; that joint are not required.
187 ;; 2. Include results of all diagnostic and clinical tests in the
188 ;; examination report.
189 ;;
190 ;;
191 ;;F. Diagnosis:
192 ;;
193 ;;
194 ;;G. Additional Limitation of Joint Function:
195 ;;
196 ;; Impairment of joint function is determined by actual range of joint
197 ;; motion as reported in the physical examination and additional limitation
198 ;; of joint function caused by the following factors:
199 ;;
200 ;; - Pain, including pain on repeated use and pain during flare-ups
201 ;; - Fatigue
202 ;; - Weakness
203 ;; - Lack of endurance
204 ;; - Incoordination
205 ;;
206 ;; 1. Do any of the above factors additionally limit joint function?
207 ;; If so, express the additional limitation in degrees.
208 ;;
209 ;; 2. Indicate if you cannot determine, without resort to mere
210 ;; speculation, whether any of these factors cause additional functional
211 ;; loss. For example, indicate if you would need to resort to mere
212 ;; speculation in order to express additional limitation due to
213 ;; flare-ups.
214 ;;
215 ;;
216 ;;
217 ;;Signature: Date:
218 ;;END
Note: See TracBrowser for help on using the repository browser.