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1DVBCWPN1 ;ALB/CMM PERIPHERAL NERVES 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. Onset and course - If flare-ups exist, describe precipitating
14 ;; factors, aggravating factors, alleviating factors, alleviating
15 ;; medications, frequency, severity, duration, and whether the
16 ;; flare-ups include pain, weakness, fatigue, or functional loss.
17 ;;
18 ;;
19 ;; 2. Current treatment, response, and side effects.
20 ;;
21 ;;
22 ;; 3. Paresthesias, dysesthesias, other sensory abnormalities.
23 ;;
24 ;;
25 ;; 4. Describe extent to which condition interferes with daily activity.
26 ;;
27 ;;
28 ;; 5. Specify nerves involved.
29 ;;
30 ;;
31 ;;C. Physical Examination (Objective Findings):
32 ;;
33 ;; Address reach of the following and fully describe current findings:
34 ;; 1. If the disability is the result of brain disease or injury,
35 ;; spinal cord disease or injury, cervical disc disease, or
36 ;; trauma to the nerve roots themselves:
37 ;; a. Report sensory and motor impairment by reference to the
38 ;; distribution of the affected groups as paralysis,
39 ;; neuritis, or neuralgia.
40 ;;
41 ;;
42 ;; b. Report each affected extremity separately.
43 ;;
44 ;;
45 ;; 2. If disability is NOT from the above:
46 ;; a. Identify the specific major nerve involved, localize the
47 ;; lesion and describe specific impairment of motor and
48 ;; sensory function, fine motor control, etc.
49 ;;
50 ;;
51 ;; b. Characterize as paralysis, neuritis, or neuralgia, and
52 ;; indicate whether any muscle wasting or atrophy represents
53 ;; direct effect of nerve damage or merely disuse.
54 ;;
55 ;;
56 ;; c. Report each affected extremity separately.
57 ;;
58 ;;
59 ;; 3. For each joint that is affected:
60 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
61 ;; of motion, including movement against gravity and against
62 ;; strong resistance.
63 ;;
64 ;;
65 ;; b. If the joint is painful on motion, state at what point in
66 ;; the range of motion pain begins and ends.
67 ;;
68 ;;
69 ;; c. State to what extent, if any, the range of motion or
70 ;; function is ADDITIONALLY LIMITED by pain, fatigue, weakness,
71 ;; or lack of endurance. If more than one of these is present,
72 ;; state, if possible, which has the major functional impact.
73 ;;
74 ;;
75 ;;D. Diagnostic and Clinical Tests:
76 ;;
77 ;; 1. Include results of all diagnostic and clinical tests conducted
78 ;; in the examination report.
79 ;;
80 ;;
81 ;;E. Diagnosis:
82 ;;
83 ;; 1. State etiology.
84 ;;
85 ;;
86 ;;Signature: Date:
87 ;;END
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