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1DVBCWB3 ;ALB/RLC BONES WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;;
12 ;; 1. Describe details of any injury.
13 ;; 2. For episodes of osteomyelitis, location, frequency. Is there current
14 ;; active infection? If not, when was the last active infection?
15 ;; 3. History of hospitalizations or surgery, reason or type of surgery,
16 ;; location and dates, if known.
17 ;; 4. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
18 ;; drainage, instability or giving way, "locking," abnormal motion, etc.
19 ;; 5. Hand dominance and how determined.
20 ;; 6. Treatment: medication type, dose, frequency, response, and
21 ;; side effects; other treatment.
22 ;; 7. If there are periods of flare-up of bone disease:
23 ;;
24 ;; a. State their severity, frequency, and duration.
25 ;; b. Name the precipitating and alleviating factors.
26 ;; c. Estimate to what extent, if any, they affect functional
27 ;; impairment during the flare-up.
28 ;;
29 ;; 8. Describe whether crutches, brace, cane, corrective shoes, etc.,
30 ;; are needed.
31 ;; 9. Are there constitutional symptoms of bone disease?
32 ;; 10. Describe the effects of the condition on the veteran's usual
33 ;; occupation and daily activities.
34 ;; 11. History of neoplasm.
35 ;;
36 ;; a. Date of diagnosis, diagnosis.
37 ;; b. Benign or malignant.
38 ;; c. Type of treatment, dates.
39 ;; d. Last date of treatment.
40 ;;
41 ;;C. Physical Examination (Objective Findings):
42 ;;
43 ;; Address each of the following as appropriate to the disability
44 ;; being examined and fully describe current findings:
45 ;;
46 ;; 1. Describe objective evidence of deformity, angulation, false
47 ;; motion, shortening, intra articular involvement, etc.
48 ;; 2. Malunion, nonunion, any loose motion, false joint.
49 ;; 3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
50 ;; 4. For weight bearing joints (hip, knee, ankle), describe gait
51 ;; and functional limitations on standing and walking. Describe
52 ;; any callosities, breakdown, or unusual shoe wear pattern that
53 ;; would indicate abnormal weight bearing.
54 ;; 5. If ankylosis is present, describe the position of the bones
55 ;; of the joint in relationship to one another (in degrees of
56 ;; flexion, external rotation, etc.), and state whether the
57 ;; ankylosis is stable and pain free.
58 ;; 6. With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED
59 ;; JOINT IS REQUIRED. Follow JOINTS worksheet.
60 ;; 7. If shortening of the leg may be present, measure the leg
61 ;; length from the anterior superior iliac spine to the medial
62 ;; malleolus.
63 ;; 8. Are there constitutional signs of bone disease - anemia,
64 ;; weight loss, fever, debility, amyloid liver, etc.?
65 ;; 9. For genu recurvatum, acquired, traumatic: Is there weakness and
66 ;; insecurity on weight-bearing?
67 ;; 10. For malunion of os calcis or astralgus - degree of deformity (mild,
68 ;; moderate, marked).
69 ;;
70 ;;D. Diagnostic and Clinical Tests:
71 ;;
72 ;; 1. As indicated: X-rays, including special views or weight
73 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
74 ;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
75 ;; arthritis of a joint requires X-ray confirmation. Once the
76 ;; diagnosis has been confirmed in a joint, further X-rays of that
77 ;; joint are not required.
78 ;; 2. For osteomyelitis, state whether there is an involucrum,
79 ;; sequestrum, or draining sinus.
80 ;; 3. Include results of all diagnostic and clinical tests
81 ;; conducted in the examination report.
82 ;;
83 ;;E. Diagnosis:
84 ;;
85 ;;
86 ;;
87 ;;Signature: Date:
88 ;;END
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