source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNS5.m@ 1800

DVBCWNS5 ;VMP/JER - SPINE WKS TEXT - 1 ; 12/02/03 11:00am

 ;;2.7;AMIE;**60**;DEC 2, 2003

        ;

TXT     ;

        ;;

        ;;A. Review of Medical Records:

        ;;

        ;;B. Present Medical History (Subjective Complaints):

        ;;

        ;;Please comment whether etiology for any of these subjective complaints is

        ;;unrelated to claimed disability.

        ;;

        ;;1.    Report complaints of pain (including any radiation), stiffness,

        ;;      weakness, etc. 

        ;;       a.     Onset 

        ;;       b.     Location and distribution 

        ;;       c.     Duration 

        ;;       d.     Characteristics, quality, description 

        ;;       e.     Intensity 

        ;;2.    Describe treatment - type, dose, frequency, response, side effects. 

        ;;3.    Report whether there are periods of flare-up. Provide the 

        ;;      following if individual reports periods of flare-up: 

        ;;       a.     Severity, frequency, and duration. 

        ;;       b.     Precipitating and alleviating factors. 

        ;;       c.     Additional limitation of motion or functional impairment during

        ;;              the flare-up. 

        ;;4.    Describe associated features or symptoms (e.g., weight loss, fevers,

        ;;      malaise, dizziness, visual disturbances, numbness, weakness,

        ;;      bladder complaints, bowel complaints, erectile dysfunction). 

        ;;5.    Describe walking and assistive devices. 

        ;;       a.     Does the veteran walk unaided? Does the veteran use a cane,

        ;;              crutches, or a walker? 

        ;;       b.     Does the veteran use a brace (orthosis)? 

        ;;       c.     How far and how long can the veteran walk? 

        ;;       d.     Is the veteran unsteady? Does the veteran have a history of

        ;;              falls? 

        ;;6.    Describe details of any trauma or injury, including dates, and direction

        ;;      and magnitude of forces. 

        ;;7.    Describe details of any surgery, including dates. 

        ;;8.    Functional Assessment - Describe effects of the condition(s) on the

        ;;      veteran's mobility (e.g., walking, transfers), activities of daily

        ;;      living (i.e., eating, grooming, bathing, toileting, dressing), usual

        ;;      occupation, recreational activities, driving. 

        ;;

        ;;C. Physical Examination (Objective Findings): Address each of the following as 

        ;;   appropriate to the condition being examined and fully describe current

        ;;   findings:

        ;; 

        ;;       1.      Inspection: spine, limbs, posture and gait, position of the

        ;;        head, curvatures of the spine, symmetry in appearance, symmetry

        ;;        and rhythm of spinal motion.

        ;;

        ;;       2.      Range of motion

        ;;

        ;;       a.      Cervical Spine 

        ;;

        ;;               The reproducibility of an individual's range of motion is one

        ;;        indicator of optimum effort. Pain, fear of injury, disuse or

        ;;        neuromuscular inhibition may limit mobility by decreasing the

        ;;        individual's effort. If range of motion measurements fail to

        ;;        match known pathology, please repeat the measurements.

        ;;        (Reference: Guides to the Evaluation of Permanent Impairment,

        ;;        Fifth Edition, 2001, page 399).

        ;; 

        ;;           i. Using a goniometer, measure and report the range of motion in

        ;;              degrees of forward flexion, extension, left lateral flexion,

        ;;              right lateral flexion, left lateral rotation and right lateral

        ;;              rotation. Generally, the normal ranges of motion for the

        ;;              cervical spine are as follows:

        ;; 

        ;;              -Forward flexion: 0 to 45 degrees 

        ;;              -Extension: 0 to 45 degrees 

        ;;              -Left Lateral Flexion: 0 to 45 degrees 

        ;;              -Right Lateral Flexion: 0 to 45 degrees 

        ;;              -Left Lateral Rotation: 0 to 80 degrees 

        ;;              -Right Lateral Rotation: 0 to 80 degrees

        ;;

        ;;      There may be a situation where an individual's range of motion is

        ;;      reduced, but "normal" (in the examiner's opinion) based on the

        ;;      individual's age, body habitus, neurologic disease, or other factors

        ;;      unrelated to the disability for which the exam is being performed. In

        ;;      this situation, please explain why the individual's measured range of

        ;;      motion should be considered as "normal".

        ;;

        ;;          ii. If the spine is painful on motion, state at what point in the

        ;;              range of motion pain begins and ends. 

        ;;

        ;;         iii. State to what extent (if any), expressed in degrees if

        ;;              possible, the range of motion is additionally limited by pain,

        ;;              fatigue, weakness, or lack of endurance following repetitive use

        ;;              or during flare-ups. If more than one of these is present, 

        ;;              state, if possible, which has the major functional impact.

        ;;

        ;;          iv. Describe objective evidence of painful motion, spasm, weakness,

        ;;              tenderness, etc.

        ;; 

        ;;           v. Describe any postural abnormalities, fixed deformity

        ;;              (ankylosis), or abnormality of musculature of cervical spine

        ;;              musculature. In the situation where there is unfavorable

        ;;              ankylosis of the cervical spine, indicate whether there is:

        ;;              difficulty walking because of a limited line of vision;

        ;;              restricted opening of the mouth (with limited ability to 

        ;;              chew); breathing limited to diaphragmatic respiration;

        ;;              gastrointestinal symptoms due to pressure of the costal margin

        ;;              on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical

        ;;              subluxation or dislocation 

        ;;

        ;;

        ;;      b. Thoracolumbar spine 

        ;;

        ;;              The reproducibility of an individual's range of motion is one

        ;;              indicator of optimum effort. Pain, fear of injury, disuse or

        ;;              neuromuscular inhibition may limit mobility by decreasing the

        ;;              individual's effort. If range of motion measurements fail to

        ;;              match known pathology, please repeat the measurements.

        ;;              (Reference: Guides to the Evaluation of Permanent Impairment,

        ;;              Fifth Edition, 2001, page 399).

        ;; 

        ;;              It is best to measure range of motion for the thoracolumbar

        ;;              spine from a standing position. Measuring the range of motion

        ;;              from a standing position (as opposed to from a sitting position)

        ;;              will include the effects of forces generated by the distance

        ;;              from the center of gravity from the axis of motion of the spine

        ;;              and will include the effect of contraction of the spinal

        ;;              muscles. Contraction of the spinal muscles imposes a significant

        ;;              compressive force during spine movements upon the lumbar discs.

        ;;

        ;;           i. Provide forward flexion of the thoracolumbar spine as a unit.

        ;;              Do not include hip flexion. (See Magee, Orthopedic Physical

        ;;              Assessment, Third Edition, 1997, W.B. Saunders Company,

        ;;              pages 374-75). Using a goniometer, measure and report the range

        ;;              of motion in degrees for forward flexion, extension, left 

        ;;              lateral flexion, right lateral flexion, left lateral rotation

        ;;              and right lateral rotation. Generally, the normal ranges of 

        ;;              motion for the thoracolumbar spine as a unit are as follows:

        ;;

        ;;  -Forward flexion: 0 to 90 degrees 

        ;;  -Extension: 0 to 30 degrees 

        ;;  -Left Lateral Flexion: 0 to 30 degrees 

        ;;  -Right Lateral Flexion: 0 to 30 degrees 

        ;;  -Left Lateral Rotation: 0 to 30 degrees 

        ;;  -Right Lateral Rotation: 0 to 30 degrees

        ;; 

        ;;There may be a situation where an individual's range of motion is reduced, but 

        ;;"normal" (in the examiner's opinion) based on the individual's age, body 

        ;;habitus, neurologic disease, or other factors unrelated to the disability for

        ;;which the exam is being performed. In this situation, please explain why the

        ;;individual's measured range of motion should be considered as "normal".

        ;; 

        ;;       ii. If the spine is painful on motion, state at what point in the range 

        ;;           of motion pain begins and ends.

        ;; 

        ;;      iii. State to what extent (if any), expressed in degrees if possible,

        ;;           the range of motion is additionally limited by pain, fatigue,

        ;;           weakness, or lack of endurance following repetitive use or during

        ;;           flare-ups. If more than one of these is present, state, if possible,

        ;;           which has the major functional impact.

        ;; 

        ;;       iv. Describe objective evidence of painful motion, spasm, weakness,

        ;;           tenderness, etc.

        ;; 

        ;;           a. Indicate whether there is muscle spasm, guarding or localized

        ;;              tenderness with preserved spinal contour, and normal gait.

        ;; 

        ;;           b. Indicate whether there is muscle spasm, or guarding severe enough

        ;;              to result in an abnormal gait, abnormal spinal contour such as

        ;;              scoliosis, reversed lordosis or abnormal kyphosis.

        ;; 

        ;;        v. Describe any postural abnormalities, fixed deformity (ankylosis), 

        ;;           or abnormality of musculature of back. In the situation where

        ;;           there is unfavorable ankylosis of the thoracolumbar spine,

        ;;           indicate whether there is: difficulty walking because of a

        ;;           limited line of vision; restricted opening of the mouth (with

        ;;           limited ability to chew); breathing limited to diaphragmatic

        ;;           respiration; gastrointestinal symptoms due to pressure of

        ;;           the costal margin on the abdomen; dyspnea; dysphagia; 

        ;;           atlantoaxial or cervical subluxation or dislocation; or

        ;;           neurologic symptoms due to nerve root involvement.

        ;;

        ;;          3. Neurological examination

        ;;

        ;;Please perform complete neurologic evaluation as indicated based upon

        ;;disability for which the exam is being performed. Please provide brief

        ;;statement if any of the following (a-e) is not included in exam. For

        ;;additional neurologic effects of disability not captured by a - e, 

        ;;(e.g. bladder problems) please refer to appropriate worksheet for the body

        ;;system affected.

        ;;

        ;;          a. Sensory examination, to include sacral segments. 

        ;;          b. Motor examination (atrophy, circumferential measurements, tone, 

        ;;             and strength). 

        ;;          c. Reflexes (deep tendon, cutaneous, and pathologic). 

        ;;          d. Rectal examination (sensation, tone, volitional control, and 

        ;;             reflexes). 

        ;;          e. Lasegue's sign.

        ;;

        ;;              4. For vertebral fractures, report the percentage of loss of

        ;;                 height, if any, of the vertebral body 

        ;;              5. Non-organic physical signs (e.g., Waddell tests, others).

        ;; 

        ;;D. For intervertebral disc syndrome

        ;;

        ;;              1. Conduct and report a separate history and physical

        ;;                 examination for each segment of the spine (cervical,

        ;;                 thoracic, lumbar) affected by disc disease. 

        ;;              2. Conduct a complete history and physical examination of each

        ;;                 affected segment of the spine (cervical, thoracic, lumbar),

        ;;                 whether or not there has been surgery, as described above

        ;;                 under B. Present Medical History and C. Physical Examination. 

        ;;              3. Conduct a thorough neurologic history and examination, as 

        ;;                 described in C5, of all areas innervated by each affected

        ;;                 spinal segment. Specify the peripheral nerve(s) affected.

        ;;                 Include an evaluation of effects, if any, on bowel or bladder

        ;;                 functioning. 

        ;;              4. Describe as precisely as possible, in number of days, the

        ;;                 duration of each incapacitating episode during the past 

        ;;                 12-month period. An incapacitating episode, for disability

        ;;                 evaluation purposes, is a period of acute signs and symptoms

        ;;                 due to intervertebral disc syndrome that requires bed rest

        ;;                 prescribed by a physician and treatment by a physician.

        ;;

        ;;E. Diagnostic and Clinical Tests:

        ;; 

        ;;  1. Imaging studies, when indicated. 

        ;;  2. Electrodiagnostic tests, when indicated. 

        ;;  3. Clinical laboratory tests, when indicated. 

        ;;  4. Isotope scans, when indicated. 

        ;;  5. Include results of all diagnostic and clinical tests conducted in the

        ;;     examination report.

        ;; 

        ;;F. Diagnosis:

        ;;

        ;; 

        ;;Signature:                                    Date:

 ;;END