source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPN1.m@ 846

DVBCWPN1 ;ALB/CMM PERIPHERAL NERVES 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.  Onset and course - If flare-ups exist, describe precipitating

 ;;        factors, aggravating factors, alleviating factors, alleviating

 ;;        medications, frequency, severity, duration, and whether the 

 ;;        flare-ups include pain, weakness, fatigue, or functional loss.

 ;;

 ;;

 ;;    2.  Current treatment, response, and side effects.

 ;;

 ;;

 ;;    3.  Paresthesias, dysesthesias, other sensory abnormalities.

 ;;

 ;;

 ;;    4.  Describe extent to which condition interferes with daily activity.

 ;;

 ;;

 ;;    5.  Specify nerves involved.

 ;;

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Address reach of the following and fully describe current findings:

 ;;    1.  If the disability is the result of brain disease or injury, 

 ;;        spinal cord disease or injury, cervical disc disease, or 

 ;;        trauma to the nerve roots themselves:

 ;;        a.  Report sensory and motor impairment by reference to the 

 ;;            distribution of the  affected groups as paralysis, 

 ;;            neuritis, or neuralgia.

 ;;

 ;;

 ;;        b.  Report each affected extremity separately.

 ;;

 ;;

 ;;    2.  If disability is NOT from the above:

 ;;        a.  Identify the specific major nerve involved, localize the 

 ;;            lesion and describe specific impairment of motor and 

 ;;            sensory function, fine motor control, etc.

 ;;

 ;;

 ;;        b.  Characterize as paralysis, neuritis, or neuralgia, and 

 ;;            indicate whether any muscle wasting or atrophy represents

 ;;            direct effect of nerve damage or merely disuse.

 ;;

 ;;

 ;;        c.  Report each affected extremity separately.

 ;;

 ;;

 ;;    3.  For each joint that is affected:

 ;;        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.

 ;;

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;    1.  State etiology.

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END