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1DVBCWSW5 ;ALB/RLC SCARS WKS TEXT - 1 ; 16 JAN 2007
2 ;;2.7;AMIE;**120**;Apr 10, 1995;Build 4
3 ;
4TXT ;
5 ;;A. Review of Medical Records:
6 ;;
7 ;;B. Medical History (Subjective Complaints):
8 ;;
9 ;; 1. Type of injury or infection causing the wound or scar, its date.
10 ;;
11 ;; 2. Current symptoms.
12 ;;
13 ;;C. Physical Examination (Objective Findings):
14 ;;
15 ;; For every scar to be examined, address EACH of the following and
16 ;; fully describe the current findings. Note that, in addition
17 ;; to measuring the scar itself, measurements of areas with certain
18 ;; abnormal characteristics must also be provided. All measurements
19 ;; should be reported in inches or centimeters.
20 ;;
21 ;; 1. Describe precise location of each scar. Draw diagram if
22 ;; necessary.
23 ;;
24 ;; 2. Give MEASUREMENT of length and width (at its widest part) of
25 ;; each scar.
26 ;;
27 ;; 3. Is there pain in the scar on examination?
28 ;;
29 ;; 4. Is there adherence to underlying tissue?
30 ;;
31 ;; 5. Texture of skin. If irregular, atrophic, shiny, scaly, etc.,
32 ;; give MEASUREMENT of length and width of area so affected.
33 ;;
34 ;; 6. Is the scar unstable, meaning is there frequent loss of
35 ;; covering of skin over the scar, such as from ulceration or
36 ;; breakdown of skin?
37 ;;
38 ;; 7. Is there elevation or depression of the surface contour
39 ;; of the scar on palpation?
40 ;;
41 ;; 8. Is the scar superficial (meaning there is no underlying
42 ;; soft tissue damage)?
43 ;;
44 ;; 9. Is the scar deep (meaning there is underlying soft tissue
45 ;; loss or damage)? If yes, give MEASUREMENT of length and
46 ;; width of underlying soft tissue damage.
47 ;;
48 ;; 10. Describe any inflammation, edema, or keloid formation.
49 ;;
50 ;; 11. Describe color of scar compared to normal areas of skin
51 ;; (give MEASUREMENT of length and width of any hypopigmentation
52 ;; or hyperpigmentation).
53 ;;
54 ;; 12. For face, discuss whether there is gross distortion or
55 ;; asymmetry of any feature or set of paired features (nose,
56 ;; chin, forehead, eyes (including eyelids), ears (auricles),
57 ;; cheeks, lips).
58 ;;
59 ;; 13. Is there an area of induration and inflexibility of skin in
60 ;; the area of the scar? If so, give MEASUREMENT of length
61 ;; and width of area of induration.
62 ;;
63 ;; 14. Describe any limitation of motion or other limitation of
64 ;; function caused by a scar.
65 ;;
66 ;; 15. With disfigurement or disfiguring scar of head, face, or
67 ;; neck, submit COLOR PHOTOGRAPHS.
68 ;;
69 ;;D. Diagnostic and Clinical Tests:
70 ;;
71 ;; Include results of all diagnostic and clinical tests conducted
72 ;; in the examination report.
73 ;;
74 ;;
75 ;;E. Diagnosis:
76 ;;
77 ;;
78 ;;Signature: Date:
79 ;;END
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