source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWSW3.m@ 776

DVBCWSW3 ;ALB/CMM SCARS WKS TEXT - 1 ; 11/20/02 3:04pm
 ;;2.7;AMIE;**49**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    1.  Type of injury or infection causing the wound or scar, its 
 ;;        date, the treatment used, and the response to such treatment.
 ;;
 ;;
 ;;    2.  Current symptoms.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    For every scar to be examined, address EACH of the following and
 ;;    fully describe the current findings.  Note that, in addition
 ;;    to measuring the scar itself, measurements of areas with certain
 ;;    abnormal characteristics must also be provided.  All measurements
 ;;    should be reported in inches or centimeters.
 ;;    1.  Describe precise location of each scar.  Draw diagram if 
 ;;        necessary.
 ;;
 ;;
 ;;    2.  Give MEASUREMENT of length and width (at its widest part) of
 ;;        each scar.
 ;;
 ;;
 ;;    3.  Is there pain in the scar on examination?
 ;;
 ;;
 ;;    4.  Is there adherence to underlying tissue?
 ;;
 ;;
 ;;    5.  Texture of skin.  If irregular, atrophic, shiny, scaly, etc.,
 ;;         give MEASUREMENT of length and width of area so affected.
 ;;
 ;;
 ;;    6.  Is the scar unstable, meaning is there frequent loss of 
 ;;        covering of skin over the scar, such as from ulceration or
 ;;        breakdown of skin?
 ;;
 ;;
 ;;    7.  Is there elevation or depression of the surface contour
 ;;        of the scar on palpation?
 ;;
 ;;
 ;;    8.  Is the scar superficial (meaning there is no underlying
 ;;        soft tissue damage)?
 ;;
 ;;
 ;;    9.  Is the scar deep (meaning there is underlying soft tissue
 ;;        loss or damage)?  If yes, give MEASUREMENT of length and
 ;;        width of underlying soft tissue damage.
 ;;
 ;;
 ;;   10.  Describe any inflammation, edema, or keloid formation.
 ;;
 ;;
 ;;   11.  Describe color of scar compared to normal areas of skin
 ;;        (give MEASUREMENT of length and width of any hypopigmentation 
 ;;        or hyperpigmentation). 
 ;;
 ;;
 ;;   12.  For face, discuss whether there is gross distortion or 
 ;;        asymmetry of any feature or set of paired features (nose,
 ;;        chin, forehead, eyes (including eyelids), ears (auricles),
 ;;        cheeks, lips).
 ;;
 ;;
 ;;   13.  Is there an area of induration and inflexibility of skin in
 ;;        the area of the scar?  If so, give MEASUREMENT of length
 ;;        and width of area of induration.
 ;;
 ;;
 ;;   14.  Describe any limitation of motion or other limitation of
 ;;        function caused by a scar.
 ;;
 ;;
 ;;   15.  With disfigurement or disfiguring scar of head, face, or
 ;;        neck, submit COLOR PHOTOGRAPHS.
 ;;        
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    Include results of all diagnostic and clinical tests conducted
 ;;    in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END