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 Apr 09, 2024@20:44:32 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
