source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPN1.m@ 1507

DVBCWPN1 ;ALB/CMM PERIPHERAL NERVES 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.  Onset and course - If flare-ups exist, describe precipitating
 ;;        factors, aggravating factors, alleviating factors, alleviating
 ;;        medications, frequency, severity, duration, and whether the 
 ;;        flare-ups include pain, weakness, fatigue, or functional loss.
 ;;
 ;;
 ;;    2.  Current treatment, response, and side effects.
 ;;
 ;;
 ;;    3.  Paresthesias, dysesthesias, other sensory abnormalities.
 ;;
 ;;
 ;;    4.  Describe extent to which condition interferes with daily activity.
 ;;
 ;;
 ;;    5.  Specify nerves involved.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address reach of the following and fully describe current findings:
 ;;    1.  If the disability is the result of brain disease or injury, 
 ;;        spinal cord disease or injury, cervical disc disease, or 
 ;;        trauma to the nerve roots themselves:
 ;;        a.  Report sensory and motor impairment by reference to the 
 ;;            distribution of the  affected groups as paralysis, 
 ;;            neuritis, or neuralgia.
 ;;
 ;;
 ;;        b.  Report each affected extremity separately.
 ;;
 ;;
 ;;    2.  If disability is NOT from the above:
 ;;        a.  Identify the specific major nerve involved, localize the 
 ;;            lesion and describe specific impairment of motor and 
 ;;            sensory function, fine motor control, etc.
 ;;
 ;;
 ;;        b.  Characterize as paralysis, neuritis, or neuralgia, and 
 ;;            indicate whether any muscle wasting or atrophy represents
 ;;            direct effect of nerve damage or merely disuse.
 ;;
 ;;
 ;;        c.  Report each affected extremity separately.
 ;;
 ;;
 ;;    3.  For each joint that is affected:
 ;;        a.  Using a goniometer, measure the PASSIVE and ACTIVE range 
 ;;            of motion, including movement against gravity and against
 ;;            strong resistance.
 ;;
 ;;
 ;;        b.  If the joint is painful on motion, state at what point in
 ;;            the range of motion pain begins and ends.
 ;;
 ;;
 ;;        c.  State to what extent, if any, the range of motion or 
 ;;            function is ADDITIONALLY LIMITED by pain, fatigue, weakness, 
 ;;            or lack of endurance.  If more than one of these is present, 
 ;;            state, if possible, which has the major functional impact.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;    1.  State etiology.
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END