source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWB1.m@ 1780

DVBCWB1 ;ALB/CMM BONES 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.  Describe details of any injury, episodes of osteomyelitis, or

 ;;        surgery.

 ;;

 ;;

 ;;    2.  Symptoms of pain, weakness, stiffness, swelling, heat, redness,

 ;;        drainage, instability or giving way, "locking," abnormal motion, etc.

 ;;

 ;;

 ;;    3.  Treatment:  medication type, dose, frequency, response, and 

 ;;        side effects; other treatment.

 ;;

 ;;

 ;;    4.  If there are periods of flare-up of bone disease:

 ;;        a.  State their severity, frequency, and duration.

 ;;

 ;;

 ;;        b.  Name the precipitating and alleviating factors.

 ;;

 ;;

 ;;        c.  Estimate to what extent, if any, they affect functional 

 ;;            impairment during the flare-up.

 ;;

 ;;

 ;;

 ;;    5.  Is there current active infection?  If not, when was the last

 ;;        active infection?  How was it determined?

 ;;

 ;;

 ;;    6.  Describe whether crutches, brace, cane, corrective shoes, etc.,

 ;;        are needed.

 ;;

 ;;

 ;;    7.  Are there constitutional symptoms of bone disease?

 ;;

 ;;

 ;;    8.  Describe the effects of the condition on the veteran's usual 

 ;;        occupation and daily activities.

 ;;

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;     Address each of the following as appropriate to the disability 

 ;;     being examined and fully describe current findings:

 ;;

 ;;     1.  Describe objective evidence of deformity, angulation, false 

 ;;         motion, shortening, intra-articular involvement, etc.

 ;;

 ;;

 ;;     2.  Malunion, nonunion, any loose motion, false joint.

 ;;

 ;;

 ;;     3.  Tenderness, drainage, edema, painful motion, weakness, redness, heat.

 ;;

 ;;

 ;;     4.  For weight bearing joints (hip, knee, ankle), describe gait

 ;;         and functional limitations on standing and walking.  Describe

 ;;         any callosities, breakdown, or unusual shoe wear pattern that

 ;;         would indicate abnormal weight bearing.

 ;;

 ;;

 ;;     5.  If ankylosis is present, describe the position of the bones 

 ;;         of the joint in relationship to one another (in degrees of 

 ;;         flexion, external rotation, etc.), and state whether the 

 ;;         ankylosis is stable and pain free.

 ;;

 ;;

 ;;     6.  With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED 

 ;;         JOINT IS REQUIRED.  

 ;;     NOTE:  See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and 

 ;;     Ankle for normal range of motion of those joints.

 ;;

 ;;

 ;;         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.

 ;;

 ;;

 ;;     7.  If shortening of the leg may be present, measure the leg 

 ;;         length from the anterior superior iliac spine to the medial 

 ;;         malleolus.

 ;;

 ;;

 ;;     8.  Are there constitutional signs of bone disease - anemia, 

 ;;         weight loss, fever, debility, amyloid liver, etc.?

 ;;

 ;;

 ;;

 ;;D.   Diagnostic and Clinical Tests:

 ;;

 ;;     1.  As indicated:  X-rays, including special views or weight 

 ;;         bearing films, MRI, arthrogram, diagnostic arthroscopy.  

 ;;     NOTE:  The diagnosis of degenerative arthritis or post-traumatic

 ;;     arthritis of a joint requires X-ray confirmation.  Once the 

 ;;     diagnosis has been confirmed in a joint, further X-rays of that 

 ;;     joint are not required.

 ;;     2.  For osteomyelitis, state whether there is an involucrum, 

 ;;         sequestrum, or draining sinus.

 ;;     3.  Include results of all diagnostic and clinical tests 

 ;;         conducted in the examination report.

 ;;

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;

 ;;

 ;;Signature:                                   Date:

 ;;END