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1DVBCWNS3 ;BPOIFO/ESW - SPINE WKS TEXT - 1 ; 10/8/02 10:52am
2 ;;2.7;AMIE;**46**;Apr 10, 1995
3 ;Per VHA Directive 10-92-142, this routine should not be modified
4 ;
5TXT ;
6 ;;
7 ;;A. Review of Medical Records: Report whether done or not.
8 ;;
9 ;;
10 ;;B. Present Medical History (Subjective Complaints):
11 ;;
12 ;; 1. Report complaints of pain (including any radiation), stiffness,
13 ;; weakness, etc.
14 ;; a. Onset
15 ;; b. Location and distribution
16 ;; c. Duration
17 ;; d. Characteristics, quality, description
18 ;; e. Intensity
19 ;; 2. Describe treatment - type, dose, frequency, response, side effects.
20 ;; 3. If there are periods of flare-up:
21 ;; a. State their severity, frequency, and duration.
22 ;; b. Name the precipitating and alleviating factors.
23 ;; c. Describe any additional limitation of motion or functional
24 ;; impairment during the flare-up.
25 ;; 4. Describe associated features or symptoms (e.g., weight loss, fevers,
26 ;; malaise, dizziness, visual disturbances, numbness, weakness, bladder
27 ;; complaints, bowel complaints, erectile dysfunction).
28 ;; 5. Describe walking and assistive devices.
29 ;; a. Walk unaided? Use of a cane, crutches, walker?
30 ;; b. Use of orthosis (brace)?
31 ;; c. How far and how long can the veteran walk?
32 ;; d. Unsteadiness? Falls?
33 ;; 6. Describe details of any trauma or injury, including dates,
34 ;; and direction and magnitude of forces.
35 ;; 7. Describe details of any surgery, including dates.
36 ;; 8. Functional Assessment - Describe effects of the condition(s) on
37 ;; the veteran's mobility (e.g., walking, transfers, bed activities),
38 ;; activities of daily living (i.e., eating, grooming, bathing,
39 ;; toileting, dressing), usual occupation, recreational activities,
40 ;; driving.
41 ;;
42 ;;C. Physical Examination (Objective Findings):
43 ;;
44 ;;Address each of the following as appropriate to the condition being examined and
45 ;;fully describe current findings:
46 ;; 1. Inspection: spine, limbs, posture and gait, position of the head,
47 ;; curvatures of the spine, symmetry in appearance, symmetry and rhythm of
48 ;; spinal motion.
49 ;; 2. Range of motion
50 ;; a. Using a goniometer, measure the range of motion, and show
51 ;; each measured range of motion (flexion, extension, etc.)
52 ;; separately rather than as a continuum. Measure active range of
53 ;; motion, and passive range of motion if active range of motion
54 ;; is not normal.
55 ;; b. State the normal range of motion when providing spine range
56 ;; of motion. For example, state forward flexion of the lumbar spine
57 ;; is 80 out of 90 degrees, and backward extension is 20 out of 35
58 ;; degrees. (See Chapter 11 of Clinician's Guide for more detailed
59 ;; discussion of spine range of motion.)
60 ;; c. If the range of motion is affected by factors other than
61 ;; spinal injury or disease, such as the claimant's body habitus,
62 ;; provide an estimated normal range of motion for that particular
63 ;; individual.
64 ;; d. If the spine is painful on motion, state at what point in
65 ;; the range of motion pain begins and ends.
66 ;; e. State to what extent (if any), expressed in degrees if
67 ;; possible, the range of motion is a d d i t i o n a l l y
68 ;; l i m i t e d by pain, fatigue, weakness, or lack of endurance
69 ;; following repetitive use or during flare-ups.
70 ;; If more than one of these
71 ;; If more than one of these is present, state, if possible, which
72 ;; has the major functional impact.
73 ;; 3. Describe objective evidence of painful motion, spasm, weakness,
74 ;; tenderness, etc.
75 ;; 4. Describe any postural abnormalities, fixed deformity (ankylosis), or
76 ;; abnormality of musculature of back.
77 ;; 5. Neurological examination
78 ;; a. Sensory examination, to include sacral segments.
79 ;; b. Motor examination (atrophy, circumferential measurements, tone,
80 ;; and strength).
81 ;; c. Reflexes (deep tendon, cutaneous, and pathologic).
82 ;; d. Rectal examination (sensation, tone, volitional control,
83 ;; and reflexes).
84 ;; e. Lasegue's sign.
85 ;; f. If the neurologic effects are not encompassed by this part
86 ;; of the examination (e.g., if there are bladder problems),
87 ;; follow appropriate worksheet for the body system affected.
88 ;; 6. For vertebral fractures, report the percentage of loss of height, if any,
89 ;; of the vertebral body.
90 ;; 7. Non-organic physical signs (e.g., Waddell tests, others).
91 ;;
92 ;;D. For intervertebral disc syndrome
93 ;;
94 ;; 1. Conduct and report a separate history and physical examination for
95 ;; each segment of the spine (cervical, thoracic, lumbar) affected by
96 ;; disc disease.
97 ;; 2. Conduct a complete history and physical examination of each affected
98 ;; spinal segment, whether or not there has been surgery, as described
99 ;; above under B and C.
100 ;; 3. Conduct a thorough neurologic history and examination, as described
101 ;; in C5, of all areas innervated by each affected spinal segment.
102 ;; Specify the peripheral nerve(s) affected. Include an evaluation of
103 ;; effects, if any, on bowel or bladder functioning.
104 ;; 4. Describe as precisely as possible, in number of days, the duration
105 ;; of each incapacitating episode during the past 12-month period.
106 ;; An incapacitating episode, for disability evaluation purposes,
107 ;; is a period of acute signs and symptoms due to intervertebral disk
108 ;; syndrome that requires bed rest prescribed by a physician and
109 ;; treatment by a physician.
110 ;;
111 ;;E. Diagnostic and Clinical Tests:
112 ;;
113 ;; 1. Imaging studies, when indicated.
114 ;; 2. Electrodiagnostic tests, when indicated.
115 ;; 3. Clinical laboratory tests, when indicated.
116 ;; 4. Isotope scans, when indicated.
117 ;; 5. Include results of all diagnostic and clinical tests conducted
118 ;; in the examination report.
119 ;;
120 ;;F. Diagnosis:
121 ;;
122 ;;
123 ;;Signature: Date:
124 ;;END
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