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1DVBCWMW1 ;ALB/CMM MUSCLES 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. If there are periods of flare-up of residuals of muscle injury:
14 ;; a. State their severity, frequency, and duration.
15 ;;
16 ;;
17 ;; b. Name the precipitating and alleviating factors.
18 ;;
19 ;;
20 ;; c. Estimate to what extent, if any, they result in additional
21 ;; limitation of motion or functional impairment during the
22 ;; flare-up.
23 ;;
24 ;;
25 ;; 2. If injury is due to a missile: initial treatment in the field,
26 ;; length of initial hospitalization and any surgeries or other
27 ;; repairs undertaken, time until return to duty or limited duty
28 ;; or determination that duty could not be resumed.
29 ;;
30 ;;
31 ;; 3. Record exact muscles injured or destroyed and describe.
32 ;;
33 ;;
34 ;; 4. Record any associated injuries, particularly those affecting
35 ;; bony structures, nerves or vascular structures and specify the
36 ;; nature of treatment required.
37 ;;
38 ;;
39 ;; 5. Describe present symptoms of muscle pain, activity limited by
40 ;; fatigue or inability to move joint through a portion of its
41 ;; range; and the degree to which this interferes with activities
42 ;; of daily living.
43 ;;
44 ;;
45 ;; 6. For tumors of muscle, describe onset of symptoms, date(s) of
46 ;; biopsy and/or surgical excision and residual defects. If
47 ;; malignant neoplasm, need dates of diagnosis, dates and type of
48 ;; treatment, and date of late treatment.
49 ;;
50 ;;
51 ;;C. Physical Examination (Objective Findings):
52 ;;
53 ;; Address each of the following and fully describe current findings:
54 ;; 1. Entry and exit wound scars as well as dimensions.
55 ;;
56 ;;
57 ;; 2. Tissue loss comparison, and specify muscle group(s) penetrated.
58 ;;
59 ;;
60 ;; 3. Scar formation measurement (sensitivity, tenderness, etc.)
61 ;;
62 ;;
63 ;; 4. Adhesions.
64 ;;
65 ;;
66 ;; 5. Tendon damage.
67 ;;
68 ;;
69 ;; 6. Bone, joint or nerve damage.
70 ;;
71 ;;
72 ;; 7. Muscle strength.
73 ;;
74 ;;
75 ;; 8. Muscle herniation and, if any, whether supported by truss or
76 ;; belt.
77 ;;
78 ;;
79 ;; 9. Loss of muscle function. Can muscle group move joint through
80 ;; normal range with sufficient comfort, endurance and strength
81 ;; to accomplish activities of daily living? Can muscle group
82 ;; move joint independently through useful ranges of motion but
83 ;; with limitation by pain or easy fatigability or weakness?
84 ;; Can muscle group move joint only with assistance or with
85 ;; gravity eliminated? Is there no ability of muscle group to
86 ;; move joint even with gravity eliminated and joint passively
87 ;; moveable? Is any muscle contraction felt?
88 ;;
89 ;;
90 ;; 10. If joint function is affected:
91 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
92 ;; of motion, including movement against gravity and against
93 ;; strong resistance.
94 ;;
95 ;;TOF
96 ;; b. State to what extent (if any) and in which degrees (if
97 ;; possible) the range of motion or function is ADDITIONALLY
98 ;; LIMITED by pain, fatigue, weakness, or lack of endurance
99 ;; following repetitive use or during flare-ups. If more
100 ;; than one of these is present, state, if possible, which
101 ;; has the major functional impact.
102 ;;
103 ;;
104 ;;D. Diagnostic and Clinical Tests:
105 ;;
106 ;; 1. If applicable, x-rays of joint(s) involved in two planes or
107 ;; anatomic area involved if not recorded in past (once taken,
108 ;; the x-rays do not need to be repeated).
109 ;; 2. Include results of all diagnostic and clinical tests conducted
110 ;; in the examination report.
111 ;;
112 ;;
113 ;;E. Diagnosis:
114 ;;
115 ;;
116 ;;Signature: Date:
117 ;;END
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