source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWJW5.m@ 635

DVBCWJW5 ;ALB/RLC JOINTS WKS TEXT - 1 ; 7 APRIL 2005
 ;;2.7;AMIE;**94**;FEB 17, 2004
 ;
 ;
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.  State to what extent, if any, per veteran, 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.
 ;;    9.  Dominance of extremity 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.  Describe presence or absence of: pain (including pain on repeated
 ;;        use); fatigue; weakness; lack of endurance; and incoordination.  
 ;;    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.)
 ;;
 ;;            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:
 ;;
 ;;               i. 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.
 ;;              ii. 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. 
 ;;        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.
 ;;    2.  Include results of all diagnostic and clinical tests in the
 ;;        examination report.
 ;;
 ;;
 ;;F.  Diagnosis:
 ;;
 ;;
 ;;G.  Additional Limitation of Joint Function:
 ;;
 ;;    Impairment of joint function is determined by actual range of joint
 ;;    motion as reported in the physical examination and additional limitation
 ;;    of joint function caused by the following factors:
 ;;
 ;;       - Pain, including pain on repeated use and pain during flare-ups
 ;;       - Fatigue
 ;;       - Weakness
 ;;       - Lack of endurance
 ;;       - Incoordination
 ;;
 ;;    1.  Do any of the above factors additionally limit joint function?
 ;;    If so, express the additional limitation in degrees.
 ;;
 ;;    2.  Indicate if you cannot determine, without resort to mere
 ;;    speculation, whether any of these factors cause additional functional
 ;;    loss.  For example, indicate if you would need to resort to mere
 ;;    speculation in order to express additional limitation due to
 ;;    flare-ups.
 ;;
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END