DVBCWB1.m

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 ---DVBCWB1   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