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[613]1DVBCWB1 ;ALB/CMM BONES 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. Describe details of any injury, episodes of osteomyelitis, or
14 ;; surgery.
15 ;;
16 ;;
17 ;; 2. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
18 ;; drainage, instability or giving way, "locking," abnormal motion, etc.
19 ;;
20 ;;
21 ;; 3. Treatment: medication type, dose, frequency, response, and
22 ;; side effects; other treatment.
23 ;;
24 ;;
25 ;; 4. If there are periods of flare-up of bone disease:
26 ;; a. State their severity, frequency, and duration.
27 ;;
28 ;;
29 ;; b. Name the precipitating and alleviating factors.
30 ;;
31 ;;
32 ;; c. Estimate to what extent, if any, they affect functional
33 ;; impairment during the flare-up.
34 ;;
35 ;;
36 ;;
37 ;; 5. Is there current active infection? If not, when was the last
38 ;; active infection? How was it determined?
39 ;;
40 ;;
41 ;; 6. Describe whether crutches, brace, cane, corrective shoes, etc.,
42 ;; are needed.
43 ;;
44 ;;
45 ;; 7. Are there constitutional symptoms of bone disease?
46 ;;
47 ;;
48 ;; 8. Describe the effects of the condition on the veteran's usual
49 ;; occupation and daily activities.
50 ;;
51 ;;
52 ;;C. Physical Examination (Objective Findings):
53 ;;
54 ;; Address each of the following as appropriate to the disability
55 ;; being examined and fully describe current findings:
56 ;;
57 ;; 1. Describe objective evidence of deformity, angulation, false
58 ;; motion, shortening, intra-articular involvement, etc.
59 ;;
60 ;;
61 ;; 2. Malunion, nonunion, any loose motion, false joint.
62 ;;
63 ;;
64 ;; 3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
65 ;;
66 ;;
67 ;; 4. For weight bearing joints (hip, knee, ankle), describe gait
68 ;; and functional limitations on standing and walking. Describe
69 ;; any callosities, breakdown, or unusual shoe wear pattern that
70 ;; would indicate abnormal weight bearing.
71 ;;
72 ;;
73 ;; 5. If ankylosis is present, describe the position of the bones
74 ;; of the joint in relationship to one another (in degrees of
75 ;; flexion, external rotation, etc.), and state whether the
76 ;; ankylosis is stable and pain free.
77 ;;
78 ;;
79 ;; 6. With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED
80 ;; JOINT IS REQUIRED.
81 ;; NOTE: See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and
82 ;; Ankle for normal range of motion of those joints.
83 ;;
84 ;;
85 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
86 ;; of motion, including movement against gravity and against
87 ;; strong resistance.
88 ;;
89 ;;
90 ;; b. If the joint is painful on motion, state at what point in
91 ;; the range of motion pain begins and ends.
92 ;;
93 ;;
94 ;; c. State to what extent, if any, the range of motion or
95 ;; function is ADDITIONALLY limited by pain, fatigue,
96 ;; weakness, or lack of endurance. If more than one of
97 ;; these is present, state, if possible, which has the major
98 ;; functional impact.
99 ;;
100 ;;
101 ;; 7. If shortening of the leg may be present, measure the leg
102 ;; length from the anterior superior iliac spine to the medial
103 ;; malleolus.
104 ;;
105 ;;
106 ;; 8. Are there constitutional signs of bone disease - anemia,
107 ;; weight loss, fever, debility, amyloid liver, etc.?
108 ;;
109 ;;
110 ;;
111 ;;D. Diagnostic and Clinical Tests:
112 ;;
113 ;; 1. As indicated: X-rays, including special views or weight
114 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
115 ;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
116 ;; arthritis of a joint requires X-ray confirmation. Once the
117 ;; diagnosis has been confirmed in a joint, further X-rays of that
118 ;; joint are not required.
119 ;; 2. For osteomyelitis, state whether there is an involucrum,
120 ;; sequestrum, or draining sinus.
121 ;; 3. Include results of all diagnostic and clinical tests
122 ;; conducted in the examination report.
123 ;;
124 ;;
125 ;;
126 ;;E. Diagnosis:
127 ;;
128 ;;
129 ;;
130 ;;Signature: Date:
131 ;;END
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