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Routine: DVBCQWR2

DVBCQWR2.m

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  1. DVBCQWR2 ;;ALB-CIOFO/SBW - Wrist Conditions ; 6/JUN/2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever had a wrist condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to wrist conditions:
  1.  ;; Diagnosis #1: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; Diagnosis #2: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; Diagnosis #3: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to wrist conditions, list
  1.  ;; using above format: ________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;; a. Describe the history (including onset and course) of the Veteran's current
  1.  ;; wrist condition(s) (brief summary): ________________________________________
  1.  ;;
  1.  ;; b. Dominant hand:
  1.  ;; ___ Right   ___ Left   ___ Ambidextrous
  1.  ;;
  1.  ;; 3. Flare-ups
  1.  ;; Does the Veteran report that flare-ups impact the function of the wrist?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, document the Veteran's description of the impact of flare-ups in his
  1.  ;; or her own words: __________________________________________________________
  1.  ;;
  1.  ;; 4. Initial range of motion (ROM) measurements
  1.  ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5 
  1.  ;; degrees. During the measurements, document the point at which painful motion
  1.  ;; begins, evidenced by visible behavior such as facial expression, wincing, etc.
  1.  ;; Report initial measurements below.
  1.  ;;
  1.  ;; Following the initial assessment of ROM, perform repetitive use testing.  For
  1.  ;; VA purposes, repetitive use testing must be included in all joint exams. The
  1.  ;; VA has determined that 3 repetitions of ROM (at a minimum) can serve as a
  1.  ;; representative test of the effect of repetitive use. After the initial
  1.  ;; measurement, reassess ROM after 3 repetitions. Report post-test measurements
  1.  ;; in section 5.
  1.  ;;
  1.  ;; a. Right wrist palmar flexion
  1.  ;; Select where palmar flexion ends (endpoint of palmar flexion is 80 degrees):
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70  ___75  ___80 or greater
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; b. Right wrist dorsiflexion (extension)
  1.  ;; Select where dorsiflexion (extension) ends (endpoint of dorsiflexion
  1.  ;; (extension) is 70 degrees):
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; c. Left wrist palmar flexion
  1.  ;; Select where palmar flexion ends (endpoint of palmar flexion is 80 degrees):
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70  ___75  ___80 or greater
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; d. Left wrist dorsiflexion (extension)
  1.  ;; Select where dorsiflexion (extension) ends (endpoint of dorsiflexion
  1.  ;; (extension) is 70 degrees):
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; e. If ROM does not conform to the normal range of motion identified above but
  1.  ;; is normal for this Veteran (for reasons other than a wrist condition, such as
  1.  ;; age, body habitus, neurologic disease), explain: ___________________________
  1.  ;;^TOF^
  1.  ;; 5. ROM measurements after repetitive use testing
  1.  ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
  1.  ;; ___ Yes   ___ No   If unable, provide reason: ______________________________
  1.  ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
  1.  ;; If Veteran is able to perform repetitive-use testing, measure and report ROM
  1.  ;; after a minimum of 3 repetitions.
  1.  ;;
  1.  ;; b. Right wrist post-test ROM
  1.  ;; Select where palmar flexion ends:
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70  ___75  ___80 or greater
  1.  ;;
  1.  ;; Select where dorsiflexion (extension) ends:
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; c. Left wrist post-test ROM 
  1.  ;; Select where palmar flexion ends:
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70  ___75  ___80 or greater
  1.  ;;
  1.  ;; Select where dorsiflexion (extension) ends:
  1.  ;; ___0   ___5   ___10  ___15  ___20  ___25  ___30  ___35  ___40  ___45  ___50   
  1.  ;; ___55  ___60  ___65  ___70 or greater
  1.  ;;
  1.  ;; 6. Functional loss and additional limitation in ROM
  1.  ;; The following section addresses reasons for functional loss, if present, and
  1.  ;; additional loss of ROM after repetitive-use testing, if present. The VA defines
  1.  ;; functional loss as the inability to perform normal working movements of the
  1.  ;; body with normal excursion, strength, speed, coordination and/or endurance.
  1.  ;;
  1.  ;; a. Does the Veteran have additional limitation in ROM of the wrist following
  1.  ;; repetitive-use testing?
  1.  ;; ___ Yes   ___ No    
  1.  ;;
  1.  ;; b. Does the Veteran have any functional loss and/or functional impairment of
  1.  ;; the wrist?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. If the Veteran has functional loss, functional impairment and/or additional
  1.  ;; limitation of ROM of the wrist after repetitive use, indicate the contributing
  1.  ;; factors of disability below (check all that apply and indicate side affected):
  1.  ;;    ___ No functional loss for right upper extremity
  1.  ;;    ___ No functional loss for left upper extremity
  1.  ;;    ___ Less movement than normal      ___ Right   ___ Left   ___ Both
  1.  ;;    ___ More movement than normal      ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Weakened movement              ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Excess fatigability            ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Incoordination, (impaired      ___ Right   ___ Left   ___ Both
  1.  ;;        ability to execute skilled movements smoothly)
  1.  ;;    ___ Pain on movement               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Swelling                       ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Deformity                      ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Atrophy of disuse              ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 7. Pain (pain on palpation)
  1.  ;; Does the Veteran have localized tenderness or pain on palpation of joints/soft
  1.  ;; tissue of either wrist?  
  1.  ;; ___ Yes   ___ No  
  1.  ;;      If yes, side affected:           ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 8. Muscle strength testing
  1.  ;; Rate strength according to the following scale:
  1.  ;;        0/5 No muscle movement  
  1.  ;;        1/5 Palpable or visible muscle contraction, but no joint movement
  1.  ;;        2/5 Active movement with gravity eliminated
  1.  ;;        3/5 Active movement against gravity
  1.  ;;        4/5 Active movement against some resistance
  1.  ;;        5/5 Normal strength
  1.  ;;    Wrist flexion:   Right: ___5/5  ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
  1.  ;;                     Left:  ___5/5  ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
  1.  ;;    Wrist extension: Right: ___5/5  ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
  1.  ;;                     Left:  ___5/5  ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
  1.  ;;
  1.  ;; 9. Ankylosis
  1.  ;; Does the Veteran have ankylosis of either wrist joint?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, indicate severity and side affected:
  1.  ;;    ___ Extremely unfavorable              ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Unfavorable, with ulnar or radial  ___ Right   ___ Left   ___ Both
  1.  ;;        deviation
  1.  ;;    ___ Unfavorable, in any degree of      ___ Right   ___ Left   ___ Both
  1.  ;;        palmar flexion
  1.  ;;    ___ Any other unfavorable position     ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Favorable in 20º to 30º            ___ Right   ___ Left   ___ Both
  1.  ;;        dorsiflexion
  1.  ;;^TOF^
  1.  ;; 10.  Joint replacement and/or other surgical procedures
  1.  ;; a. Has the Veteran had a total wrist joint replacement?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side and severity of residuals.       
  1.  ;;    ___ Right wrist
  1.  ;;       Date of surgery: ___________________
  1.  ;;          Residuals:
  1.  ;;          ___ None
  1.  ;;          ___ Intermediate degrees of residual weakness, pain and/or
  1.  ;;              limitation of motion
  1.  ;;          ___ Chronic residuals consisting of severe painful motion and/or
  1.  ;;              weakness
  1.  ;;          ___ Other, describe: _____________
  1.  ;;    ___ Left wrist
  1.  ;;       Date of surgery: ___________________
  1.  ;;          Residuals:
  1.  ;;          ___ None
  1.  ;;          ___ Intermediate degrees of residual weakness, pain and/or
  1.  ;;              limitation of motion
  1.  ;;          ___ Chronic residuals consisting of severe painful motion and/or 
  1.  ;;              weakness
  1.  ;;          ___ Other, describe: _____________
  1.  ;;
  1.  ;; b. Has the Veteran had arthroscopic or other wrist surgery?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:       ___ Right   ___ Left   ___ Both
  1.  ;;    Date and type of surgery: _____________
  1.  ;;
  1.  ;; c. Does the Veteran have any residual signs and/or symptoms due to
  1.  ;; arthroscopic or other wrist  surgery?    
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, indicate side affected:       ___ Right   ___ Left   ___ Both
  1.  ;;     If yes, describe residuals: _________________________ 
  1.  ;;
  1.  ;; 11. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?  
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area of
  1.  ;; all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;        If yes, also complete a Scars Questionnaire.
  1.  ;;^TOF^
  1.  ;; b.  Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 12. Remaining effective function of the extremities
  1.  ;; Due to the Veteran's wrist conditions, is there functional impairment of an
  1.  ;; extremity such that no effective function remains other than that which would
  1.  ;; be equally well served by an amputation with prosthesis? (Functions of the
  1.  ;; upper extremity include grasping, manipulation, etc)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;;     equally serve the Veteran.
  1.  ;; ___ No
  1.  ;; If yes, indicate extremity(ies) (check all extremities for which this applies):
  1.  ;;    ___ Right upper    ___ Left upper
  1.  ;; For each checked extremity, describe loss of effective function, identify the
  1.  ;; condition causing loss of function, and provide specific examples (brief
  1.  ;; summary): __________________________________________________________________
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 13.  Diagnostic Testing
  1.  ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis
  1.  ;; must be confirmed by imaging studies. Once such arthritis has been documented,
  1.  ;; no further imaging studies are indicated, even if arthritis has worsened.
  1.  ;;
  1.  ;; a. Have imaging studies of the wrist been performed and are the results
  1.  ;; available?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is degenerative or traumatic arthritis documented?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, indicate wrist:           ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 14. Functional impact
  1.  ;; Does the Veteran's wrist condition impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's wrist conditions
  1.  ;; providing one or more examples: ____________________________________________
  1.  ;; ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 15. Remarks, if any:  ______________________________________________________
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _____________________________________________________
  1.  ;;
  1.  ;; Medical license #: __________________________________________________________
  1.  ;;
  1.  ;; Physician address: __________________________________________________________
  1.  ;;
  1.  ;; Phone: _____________________________     FAX: _______________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's application.
  1.  ;;^END^
  1.  Q