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Routine: DVBCWB1

DVBCWB1.m

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  1. DVBCWB1 ;ALB/CMM BONES WKS TEXT - 1 ; 6 MARCH 1997
  1. ;;2.7;AMIE;**12**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;;
  1. ;; Comment on:
  1. ;; 1. Describe details of any injury, episodes of osteomyelitis, or
  1. ;; surgery.
  1. ;;
  1. ;;
  1. ;; 2. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
  1. ;; drainage, instability or giving way, "locking," abnormal motion, etc.
  1. ;;
  1. ;;
  1. ;; 3. Treatment: medication type, dose, frequency, response, and
  1. ;; side effects; other treatment.
  1. ;;
  1. ;;
  1. ;; 4. If there are periods of flare-up of bone disease:
  1. ;; a. State their severity, frequency, and duration.
  1. ;;
  1. ;;
  1. ;; b. Name the precipitating and alleviating factors.
  1. ;;
  1. ;;
  1. ;; c. Estimate to what extent, if any, they affect functional
  1. ;; impairment during the flare-up.
  1. ;;
  1. ;;
  1. ;;
  1. ;; 5. Is there current active infection? If not, when was the last
  1. ;; active infection? How was it determined?
  1. ;;
  1. ;;
  1. ;; 6. Describe whether crutches, brace, cane, corrective shoes, etc.,
  1. ;; are needed.
  1. ;;
  1. ;;
  1. ;; 7. Are there constitutional symptoms of bone disease?
  1. ;;
  1. ;;
  1. ;; 8. Describe the effects of the condition on the veteran's usual
  1. ;; occupation and daily activities.
  1. ;;
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; Address each of the following as appropriate to the disability
  1. ;; being examined and fully describe current findings:
  1. ;;
  1. ;; 1. Describe objective evidence of deformity, angulation, false
  1. ;; motion, shortening, intra-articular involvement, etc.
  1. ;;
  1. ;;
  1. ;; 2. Malunion, nonunion, any loose motion, false joint.
  1. ;;
  1. ;;
  1. ;; 3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
  1. ;;
  1. ;;
  1. ;; 4. For weight bearing joints (hip, knee, ankle), describe gait
  1. ;; and functional limitations on standing and walking. Describe
  1. ;; any callosities, breakdown, or unusual shoe wear pattern that
  1. ;; would indicate abnormal weight bearing.
  1. ;;
  1. ;;
  1. ;; 5. If ankylosis is present, describe the position of the bones
  1. ;; of the joint in relationship to one another (in degrees of
  1. ;; flexion, external rotation, etc.), and state whether the
  1. ;; ankylosis is stable and pain free.
  1. ;;
  1. ;;
  1. ;; 6. With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED
  1. ;; JOINT IS REQUIRED.
  1. ;; NOTE: See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and
  1. ;; Ankle for normal range of motion of those joints.
  1. ;;
  1. ;;
  1. ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
  1. ;; of motion, including movement against gravity and against
  1. ;; strong resistance.
  1. ;;
  1. ;;
  1. ;; b. If the joint is painful on motion, state at what point in
  1. ;; the range of motion pain begins and ends.
  1. ;;
  1. ;;
  1. ;; c. State to what extent, if any, the range of motion or
  1. ;; function is ADDITIONALLY limited by pain, fatigue,
  1. ;; weakness, or lack of endurance. If more than one of
  1. ;; these is present, state, if possible, which has the major
  1. ;; functional impact.
  1. ;;
  1. ;;
  1. ;; 7. If shortening of the leg may be present, measure the leg
  1. ;; length from the anterior superior iliac spine to the medial
  1. ;; malleolus.
  1. ;;
  1. ;;
  1. ;; 8. Are there constitutional signs of bone disease - anemia,
  1. ;; weight loss, fever, debility, amyloid liver, etc.?
  1. ;;
  1. ;;
  1. ;;
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. As indicated: X-rays, including special views or weight
  1. ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
  1. ;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
  1. ;; arthritis of a joint requires X-ray confirmation. Once the
  1. ;; diagnosis has been confirmed in a joint, further X-rays of that
  1. ;; joint are not required.
  1. ;; 2. For osteomyelitis, state whether there is an involucrum,
  1. ;; sequestrum, or draining sinus.
  1. ;; 3. Include results of all diagnostic and clinical tests
  1. ;; conducted in the examination report.
  1. ;;
  1. ;;
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END