source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWMW1.m@ 1607

DVBCWMW1 ;ALB/CMM MUSCLES 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.  If there are periods of flare-up of residuals of muscle injury:
 ;;        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.
 ;;
 ;;
 ;;    2.  If injury is due to a missile:  initial treatment in the field,
 ;;        length of initial hospitalization and any surgeries or other 
 ;;        repairs undertaken, time until return to duty or limited duty
 ;;        or determination that duty could not be resumed.
 ;;
 ;;
 ;;    3.  Record exact muscles injured or destroyed and describe.
 ;;
 ;;
 ;;    4.  Record any associated injuries, particularly those affecting 
 ;;        bony structures, nerves or vascular structures and specify the
 ;;        nature of treatment required.
 ;;
 ;;
 ;;    5.  Describe present symptoms of muscle pain, activity limited by
 ;;        fatigue or inability to move joint through a portion of its 
 ;;        range; and the degree to which this interferes with activities
 ;;        of daily living.
 ;;
 ;;
 ;;    6.  For tumors of muscle, describe onset of symptoms, date(s) of 
 ;;        biopsy and/or surgical excision and residual defects.  If 
 ;;        malignant neoplasm, need dates of diagnosis, dates and type of
 ;;        treatment, and date of late treatment.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;     Address each of the following and fully describe current findings:
 ;;     1.  Entry and exit wound scars as well as dimensions.
 ;;
 ;;
 ;;     2.  Tissue loss comparison,  and specify muscle group(s) penetrated.
 ;;
 ;;
 ;;     3.  Scar formation measurement (sensitivity, tenderness, etc.)
 ;;
 ;;
 ;;     4.  Adhesions.
 ;;
 ;;
 ;;     5.  Tendon damage.
 ;;
 ;;
 ;;     6.  Bone, joint or nerve damage.
 ;;
 ;;
 ;;     7.  Muscle strength.
 ;;
 ;;
 ;;     8.  Muscle herniation and, if any, whether supported by truss or
 ;;         belt.
 ;;
 ;;
 ;;     9.  Loss of muscle function.  Can muscle group move joint through
 ;;         normal range with sufficient comfort, endurance and strength
 ;;         to accomplish activities of daily living?  Can muscle group 
 ;;         move joint independently through useful ranges of motion but
 ;;         with limitation by pain or easy fatigability or weakness?  
 ;;         Can muscle group move joint only with assistance or with 
 ;;         gravity eliminated?  Is there no ability of muscle group to 
 ;;         move joint even with gravity eliminated and joint passively 
 ;;         moveable?  Is any muscle contraction felt?
 ;;
 ;;
 ;;    10.  If joint function is affected:
 ;;         a.  Using a goniometer, measure the PASSIVE and ACTIVE range
 ;;             of motion, including movement against gravity and against
 ;;             strong resistance.
 ;;
 ;;TOF
 ;;         b.  State to what extent (if any) and in which degrees (if 
 ;;             possible) the range of motion or 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.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  If applicable, x-rays of joint(s) involved in two planes or 
 ;;        anatomic area involved if not recorded in past (once taken, 
 ;;        the x-rays do  not need to be repeated).
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END