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1DVBCWNS1 ;ALB/CMM SPINE 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. Present Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Complaints of pain, weakness, stiffness, fatigability, lack of
14 ;; endurance, etc.
15 ;;
16 ;;
17 ;; 2. Treatment - type, dose, frequency, response, side effects.
18 ;;
19 ;;
20 ;; 3. If there are periods of flare-up:
21 ;; a. State their severity, frequency, and duration.
22 ;;
23 ;;
24 ;; b. Name the precipitating and alleviating factors.
25 ;;
26 ;;
27 ;; c. Estimate to what extent, if any, they result in additional
28 ;; limitation of motion or functional impairment during the
29 ;; flare-up.
30 ;;
31 ;;
32 ;; 4. Describe whether crutches, brace, cane, etc., are needed.
33 ;;
34 ;;
35 ;; 5. Describe details of any surgery or injury.
36 ;;
37 ;;
38 ;; 6. Functional Assessment - Describe effects of the condition(s)
39 ;; on the veteran's usual occupation and daily activities.
40 ;;
41 ;;
42 ;;C. Physical Examination (Objective Findings):
43 ;;
44 ;; Address each of the following as appropriate to the condition
45 ;; being examined and fully describe current findings:
46 ;; 1. Using a goniometer, measure the PASSIVE and ACTIVE range of
47 ;; motion, including movement against gravity and against strong
48 ;; resistance. Provide range of motion in degrees.
49 ;;
50 ;;
51 ;; 2. If the spine is painful on motion, state at what point in the
52 ;; range of motion pain begins and ends.
53 ;;
54 ;;
55 ;; 3. State to what extent (if any) and in which degrees (if possible)
56 ;; the range of motion or spinal function is ADDITIONALLY LIMITED
57 ;; by pain, fatigue, weakness, or lack of endurance following
58 ;; repetitive use or during flare-ups. If more than one of these
59 ;; is present, state, if possible, which has the major functional
60 ;; impact.
61 ;;
62 ;;
63 ;; 4. Describe objective evidence of painful motion, spasm, weakness,
64 ;; tenderness, etc.
65 ;;
66 ;;
67 ;; 5. Postural abnormalities, fixed deformity.
68 ;;
69 ;;
70 ;; 6. Musculature of back.
71 ;;
72 ;;
73 ;; 7. Neurological abnormalities - if present, see appropriate worksheet.
74 ;;
75 ;;
76 ;;D. Normal Range of Motion:
77 ;;
78 ;; All joint Range of Motion measurements must be made using a
79 ;; GONIOMETER. Show each measured range of motion separately rather
80 ;; than as a continuum.
81 ;;
82 ;;
83 ;;E. Diagnostic and Clinical Tests:
84 ;;
85 ;; Obtain the following and comment on them, as indicated:
86 ;; 1. X-rays, MRI, as indicated.
87 ;; 2. Include results of all diagnostic and clinical tests conducted
88 ;; in the examination report.
89 ;;
90 ;;
91 ;;F. Diagnosis:
92 ;;
93 ;;
94 ;;Signature: Date:
95 ;;END
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