source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNS3.m@ 1671

DVBCWNS3 ;BPOIFO/ESW - SPINE WKS TEXT - 1 ; 10/8/02 10:52am
 ;;2.7;AMIE;**46**;Apr 10, 1995
 ;Per VHA Directive 10-92-142, this routine should not be modified
 ;
TXT ;
 ;;
 ;;A. Review of Medical Records: Report whether done or not.
 ;;
 ;;
 ;;B. Present Medical History (Subjective Complaints):
 ;;
 ;;     1. Report complaints of pain (including any radiation), stiffness,
 ;;        weakness, etc.
 ;;        a. Onset
 ;;        b. Location and distribution
 ;;        c. Duration
 ;;        d. Characteristics, quality, description
 ;;        e. Intensity
 ;;     2. Describe 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.  Describe any additional limitation of motion or functional
 ;;                impairment during the flare-up.
 ;;     4. Describe associated features or symptoms (e.g., weight loss, fevers,
 ;;        malaise, dizziness, visual disturbances, numbness, weakness, bladder
 ;;        complaints, bowel complaints, erectile dysfunction).
 ;;     5. Describe walking and assistive devices.
 ;;            a.  Walk unaided?  Use of a cane, crutches, walker?
 ;;            b.  Use of orthosis (brace)?
 ;;            c.  How far and how long can the veteran walk?
 ;;            d.  Unsteadiness?  Falls?
 ;;     6. Describe details of any trauma or injury, including dates,
 ;;        and direction and magnitude of forces.
 ;;     7. Describe details of any surgery, including dates.
 ;;     8. Functional Assessment - Describe effects of the condition(s) on
 ;;        the veteran's mobility (e.g., walking, transfers, bed activities),
 ;;        activities of daily living (i.e., eating, grooming, bathing,
 ;;        toileting, dressing), usual occupation, recreational activities,
 ;;        driving.
 ;;
 ;;C. Physical Examination (Objective Findings):
 ;;
 ;;Address each of the following as appropriate to the condition being examined and
 ;;fully describe current findings:
 ;;     1. Inspection:  spine, limbs, posture and gait, position of the head,
 ;;        curvatures of the spine, symmetry in appearance, symmetry and rhythm of
 ;;        spinal motion.
 ;;     2. Range of motion
 ;;        a. Using a goniometer, measure the range of motion, and show
 ;;           each measured range of motion (flexion, extension, etc.)
 ;;           separately rather than as a continuum.  Measure active range of
 ;;           motion, and passive range of motion if active range of motion
 ;;           is not normal.
 ;;        b. State the normal range of motion when providing spine range
 ;;           of motion. For example, state forward flexion of the lumbar spine
 ;;           is 80 out of 90 degrees, and backward extension is 20 out of 35
 ;;           degrees. (See Chapter 11 of Clinician's Guide for more detailed
 ;;           discussion of spine range of motion.)
 ;;        c. If the range of motion is affected by factors other than
 ;;           spinal injury or disease, such as the claimant's body habitus,
 ;;           provide an estimated normal range of motion for that particular
 ;;           individual.
 ;;        d. If the spine is painful on motion, state at what point in
 ;;           the range of motion pain begins and ends.
 ;;        e. State to what extent (if any), expressed in degrees if
 ;;           possible, the range of motion is  a d d i t i o n a l l y
 ;;           l i m i t e d  by pain, fatigue, weakness, or lack of endurance
 ;;           following repetitive use or during flare-ups.
 ;;           If more than one of these
 ;;           If more than one of these is present, state, if possible, which
 ;;           has the major functional impact.
 ;;     3. Describe objective evidence of painful motion, spasm, weakness,
 ;;        tenderness, etc.
 ;;     4. Describe any postural abnormalities, fixed deformity (ankylosis), or
 ;;        abnormality of musculature of back.
 ;;     5. Neurological examination
 ;;           a. Sensory examination, to include sacral segments.
 ;;           b. Motor examination (atrophy, circumferential measurements, tone,
 ;;              and strength).
 ;;           c. Reflexes (deep tendon, cutaneous, and pathologic).
 ;;           d. Rectal examination (sensation, tone, volitional control,
 ;;              and reflexes).
 ;;           e. Lasegue's sign.
 ;;           f. If the neurologic effects are not encompassed by this part
 ;;              of the examination (e.g., if there are bladder problems),
 ;;              follow appropriate worksheet for the body system affected.
 ;;     6. For vertebral fractures, report the percentage of loss of height, if any,
 ;;        of the vertebral body.
 ;;     7. Non-organic physical signs (e.g., Waddell tests, others).
 ;;
 ;;D. For intervertebral disc syndrome
 ;;
 ;;     1. Conduct and report a separate history and physical examination for
 ;;        each segment of the spine (cervical, thoracic, lumbar) affected by
 ;;        disc disease. 
 ;;     2. Conduct a complete history and physical examination of each affected
 ;;        spinal segment, whether or not there has been surgery, as described
 ;;        above under B and C.
 ;;     3. Conduct a thorough neurologic history and examination, as described
 ;;        in C5, of all areas innervated by each affected spinal segment.
 ;;        Specify the peripheral nerve(s) affected. Include an evaluation of
 ;;        effects, if any, on bowel or bladder functioning.  
 ;;     4. Describe as precisely as possible, in number of days, the duration
 ;;        of each incapacitating episode during the past 12-month period.
 ;;        An incapacitating episode, for disability evaluation purposes,
 ;;        is a period of acute signs and symptoms due to intervertebral disk
 ;;        syndrome that requires bed rest prescribed by a physician and
 ;;        treatment by a physician. 
 ;;
 ;;E. Diagnostic and Clinical Tests:
 ;;
 ;;     1. Imaging studies, when indicated.  
 ;;     2. Electrodiagnostic tests, when indicated.
 ;;     3. Clinical laboratory tests, when indicated.
 ;;     4. Isotope scans, when indicated.
 ;;     5. Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;F. Diagnosis:
 ;;
 ;;
 ;;Signature:                               Date:
 ;;END