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Routine: DVBCWB3

DVBCWB3.m

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  1. DVBCWB3 ;ALB/RLC BONES WKS TEXT - 1 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records:
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    Comment on:
  1.  ;;
  1.  ;;    1.  Describe details of any injury.
  1.  ;;    2.  For episodes of osteomyelitis, location, frequency.  Is there current
  1.  ;;        active infection?  If not, when was the last active infection?
  1.  ;;    3.  History of hospitalizations or surgery, reason or type of surgery,
  1.  ;;        location and dates, if known.
  1.  ;;    4.  Symptoms of pain, weakness, stiffness, swelling, heat, redness,
  1.  ;;        drainage, instability or giving way, "locking," abnormal motion, etc.
  1.  ;;    5.  Hand dominance and how determined.
  1.  ;;    6.  Treatment:  medication type, dose, frequency, response, and 
  1.  ;;        side effects; other treatment.
  1.  ;;    7.  If there are periods of flare-up of bone disease:
  1.  ;;
  1.  ;;        a.  State their severity, frequency, and duration.
  1.  ;;        b.  Name the precipitating and alleviating factors.
  1.  ;;        c.  Estimate to what extent, if any, they affect functional 
  1.  ;;            impairment during the flare-up.
  1.  ;;
  1.  ;;    8.  Describe whether crutches, brace, cane, corrective shoes, etc.,
  1.  ;;        are needed.
  1.  ;;    9.  Are there constitutional symptoms of bone disease?
  1.  ;;    10. Describe the effects of the condition on the veteran's usual 
  1.  ;;        occupation and daily activities.
  1.  ;;    11. History of neoplasm.
  1.  ;;
  1.  ;;        a.  Date of diagnosis, diagnosis.
  1.  ;;        b.  Benign or malignant.
  1.  ;;        c.  Type of treatment, dates.
  1.  ;;        d.  Last date of treatment.
  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.  ;;     2.  Malunion, nonunion, any loose motion, false joint.
  1.  ;;     3.  Tenderness, drainage, edema, painful motion, weakness, redness, heat.
  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.  ;;     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.  ;;     6.  With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED 
  1.  ;;         JOINT IS REQUIRED.  Follow JOINTS worksheet.
  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.  ;;     8.  Are there constitutional signs of bone disease - anemia, 
  1.  ;;         weight loss, fever, debility, amyloid liver, etc.?
  1.  ;;     9.  For genu recurvatum, acquired, traumatic:  Is there weakness and
  1.  ;;         insecurity on weight-bearing?
  1.  ;;     10. For malunion of os calcis or astralgus - degree of deformity (mild,
  1.  ;;         moderate, marked).
  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.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;Signature:                                   Date:
  1.  ;;END