- DVBCWB1 ;ALB/CMM BONES 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. Describe details of any injury, episodes of osteomyelitis, or
- ;; surgery.
- ;;
- ;;
- ;; 2. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
- ;; drainage, instability or giving way, "locking," abnormal motion, etc.
- ;;
- ;;
- ;; 3. Treatment: medication type, dose, frequency, response, and
- ;; side effects; other treatment.
- ;;
- ;;
- ;; 4. If there are periods of flare-up of bone disease:
- ;; a. State their severity, frequency, and duration.
- ;;
- ;;
- ;; b. Name the precipitating and alleviating factors.
- ;;
- ;;
- ;; c. Estimate to what extent, if any, they affect functional
- ;; impairment during the flare-up.
- ;;
- ;;
- ;;
- ;; 5. Is there current active infection? If not, when was the last
- ;; active infection? How was it determined?
- ;;
- ;;
- ;; 6. Describe whether crutches, brace, cane, corrective shoes, etc.,
- ;; are needed.
- ;;
- ;;
- ;; 7. Are there constitutional symptoms of bone disease?
- ;;
- ;;
- ;; 8. Describe the effects of the condition on the veteran's usual
- ;; occupation and daily activities.
- ;;
- ;;
- ;;C. Physical Examination (Objective Findings):
- ;;
- ;; Address each of the following as appropriate to the disability
- ;; being examined and fully describe current findings:
- ;;
- ;; 1. Describe objective evidence of deformity, angulation, false
- ;; motion, shortening, intra-articular involvement, etc.
- ;;
- ;;
- ;; 2. Malunion, nonunion, any loose motion, false joint.
- ;;
- ;;
- ;; 3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
- ;;
- ;;
- ;; 4. For weight bearing joints (hip, knee, ankle), describe gait
- ;; and functional limitations on standing and walking. Describe
- ;; any callosities, breakdown, or unusual shoe wear pattern that
- ;; would indicate abnormal weight bearing.
- ;;
- ;;
- ;; 5. If ankylosis is present, describe the position of the bones
- ;; of the joint in relationship to one another (in degrees of
- ;; flexion, external rotation, etc.), and state whether the
- ;; ankylosis is stable and pain free.
- ;;
- ;;
- ;; 6. With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED
- ;; JOINT IS REQUIRED.
- ;; NOTE: See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and
- ;; Ankle for normal range of motion of those joints.
- ;;
- ;;
- ;; 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.
- ;;
- ;;
- ;; 7. If shortening of the leg may be present, measure the leg
- ;; length from the anterior superior iliac spine to the medial
- ;; malleolus.
- ;;
- ;;
- ;; 8. Are there constitutional signs of bone disease - anemia,
- ;; weight loss, fever, debility, amyloid liver, etc.?
- ;;
- ;;
- ;;
- ;;D. Diagnostic and Clinical Tests:
- ;;
- ;; 1. As indicated: X-rays, including special views or weight
- ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
- ;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
- ;; arthritis of a joint requires X-ray confirmation. Once the
- ;; diagnosis has been confirmed in a joint, further X-rays of that
- ;; joint are not required.
- ;; 2. For osteomyelitis, state whether there is an involucrum,
- ;; sequestrum, or draining sinus.
- ;; 3. Include results of all diagnostic and clinical tests
- ;; conducted in the examination report.
- ;;
- ;;
- ;;
- ;;E. Diagnosis:
- ;;
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWB1 4528 printed Feb 18, 2025@23:16:16 Page 2
- DVBCWB1 ;ALB/CMM BONES WKS TEXT - 1 ; 6 MARCH 1997
- +1 ;;2.7;AMIE;**12**;Apr 10, 1995
- +2 ;
- +3 ;
- TXT ;
- +1 ;;A. Review of Medical Records:
- +2 ;;
- +3 ;;
- +4 ;;
- +5 ;;B. Medical History (Subjective Complaints):
- +6 ;;
- +7 ;; Comment on:
- +8 ;; 1. Describe details of any injury, episodes of osteomyelitis, or
- +9 ;; surgery.
- +10 ;;
- +11 ;;
- +12 ;; 2. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
- +13 ;; drainage, instability or giving way, "locking," abnormal motion, etc.
- +14 ;;
- +15 ;;
- +16 ;; 3. Treatment: medication type, dose, frequency, response, and
- +17 ;; side effects; other treatment.
- +18 ;;
- +19 ;;
- +20 ;; 4. If there are periods of flare-up of bone disease:
- +21 ;; a. State their severity, frequency, and duration.
- +22 ;;
- +23 ;;
- +24 ;; b. Name the precipitating and alleviating factors.
- +25 ;;
- +26 ;;
- +27 ;; c. Estimate to what extent, if any, they affect functional
- +28 ;; impairment during the flare-up.
- +29 ;;
- +30 ;;
- +31 ;;
- +32 ;; 5. Is there current active infection? If not, when was the last
- +33 ;; active infection? How was it determined?
- +34 ;;
- +35 ;;
- +36 ;; 6. Describe whether crutches, brace, cane, corrective shoes, etc.,
- +37 ;; are needed.
- +38 ;;
- +39 ;;
- +40 ;; 7. Are there constitutional symptoms of bone disease?
- +41 ;;
- +42 ;;
- +43 ;; 8. Describe the effects of the condition on the veteran's usual
- +44 ;; occupation and daily activities.
- +45 ;;
- +46 ;;
- +47 ;;C. Physical Examination (Objective Findings):
- +48 ;;
- +49 ;; Address each of the following as appropriate to the disability
- +50 ;; being examined and fully describe current findings:
- +51 ;;
- +52 ;; 1. Describe objective evidence of deformity, angulation, false
- +53 ;; motion, shortening, intra-articular involvement, etc.
- +54 ;;
- +55 ;;
- +56 ;; 2. Malunion, nonunion, any loose motion, false joint.
- +57 ;;
- +58 ;;
- +59 ;; 3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
- +60 ;;
- +61 ;;
- +62 ;; 4. For weight bearing joints (hip, knee, ankle), describe gait
- +63 ;; and functional limitations on standing and walking. Describe
- +64 ;; any callosities, breakdown, or unusual shoe wear pattern that
- +65 ;; would indicate abnormal weight bearing.
- +66 ;;
- +67 ;;
- +68 ;; 5. If ankylosis is present, describe the position of the bones
- +69 ;; of the joint in relationship to one another (in degrees of
- +70 ;; flexion, external rotation, etc.), and state whether the
- +71 ;; ankylosis is stable and pain free.
- +72 ;;
- +73 ;;
- +74 ;; 6. With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED
- +75 ;; JOINT IS REQUIRED.
- +76 ;; NOTE: See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and
- +77 ;; Ankle for normal range of motion of those joints.
- +78 ;;
- +79 ;;
- +80 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
- +81 ;; of motion, including movement against gravity and against
- +82 ;; strong resistance.
- +83 ;;
- +84 ;;
- +85 ;; b. If the joint is painful on motion, state at what point in
- +86 ;; the range of motion pain begins and ends.
- +87 ;;
- +88 ;;
- +89 ;; c. State to what extent, if any, the range of motion or
- +90 ;; function is ADDITIONALLY limited by pain, fatigue,
- +91 ;; weakness, or lack of endurance. If more than one of
- +92 ;; these is present, state, if possible, which has the major
- +93 ;; functional impact.
- +94 ;;
- +95 ;;
- +96 ;; 7. If shortening of the leg may be present, measure the leg
- +97 ;; length from the anterior superior iliac spine to the medial
- +98 ;; malleolus.
- +99 ;;
- +100 ;;
- +101 ;; 8. Are there constitutional signs of bone disease - anemia,
- +102 ;; weight loss, fever, debility, amyloid liver, etc.?
- +103 ;;
- +104 ;;
- +105 ;;
- +106 ;;D. Diagnostic and Clinical Tests:
- +107 ;;
- +108 ;; 1. As indicated: X-rays, including special views or weight
- +109 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
- +110 ;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
- +111 ;; arthritis of a joint requires X-ray confirmation. Once the
- +112 ;; diagnosis has been confirmed in a joint, further X-rays of that
- +113 ;; joint are not required.
- +114 ;; 2. For osteomyelitis, state whether there is an involucrum,
- +115 ;; sequestrum, or draining sinus.
- +116 ;; 3. Include results of all diagnostic and clinical tests
- +117 ;; conducted in the examination report.
- +118 ;;
- +119 ;;
- +120 ;;
- +121 ;;E. Diagnosis:
- +122 ;;
- +123 ;;
- +124 ;;
- +125 ;;Signature: Date:
- +126 ;;END