source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNS1.m@ 1354

DVBCWNS1 ;ALB/CMM SPINE WKS TEXT - 1 ; 6 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Present Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Complaints of pain, weakness, stiffness, fatigability, lack of
 ;;        endurance, etc.
 ;;
 ;;
 ;;    2.  Treatment - type, dose, frequency, response, side effects.
 ;;
 ;;
 ;;    3.  If there are periods of flare-up:
 ;;        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.
 ;;
 ;;
 ;;    4.  Describe whether crutches, brace, cane, etc., are needed.
 ;;
 ;;
 ;;    5.  Describe details of any surgery or injury.
 ;;
 ;;
 ;;    6.  Functional Assessment  -  Describe effects of the condition(s)
 ;;        on the veteran's usual occupation and daily activities.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following as appropriate to the condition 
 ;;    being examined and fully describe current findings:
 ;;    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 spine is painful on motion, state at what point in the
 ;;        range of motion pain begins and ends.
 ;;
 ;;
 ;;    3.  State to what extent (if any) and in which degrees (if possible)
 ;;        the range of motion or spinal 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.
 ;;
 ;;
 ;;    4.  Describe objective evidence of painful motion, spasm, weakness,
 ;;        tenderness, etc.
 ;;
 ;;
 ;;    5.  Postural abnormalities, fixed deformity.
 ;;
 ;;
 ;;    6.  Musculature of back.
 ;;
 ;;
 ;;    7.  Neurological abnormalities  - if present, see appropriate worksheet.
 ;;
 ;;
 ;;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.
 ;;
 ;;
 ;;E.  Diagnostic and Clinical Tests:
 ;;
 ;;    Obtain the following and comment on them, as indicated:
 ;;    1.  X-rays, MRI, as indicated.
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;F.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END