DVBCWB3 ;ALB/RLC BONES WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. Describe details of any injury.
;; 2. For episodes of osteomyelitis, location, frequency. Is there current
;; active infection? If not, when was the last active infection?
;; 3. History of hospitalizations or surgery, reason or type of surgery,
;; location and dates, if known.
;; 4. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
;; drainage, instability or giving way, "locking," abnormal motion, etc.
;; 5. Hand dominance and how determined.
;; 6. Treatment: medication type, dose, frequency, response, and
;; side effects; other treatment.
;; 7. 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.
;;
;; 8. Describe whether crutches, brace, cane, corrective shoes, etc.,
;; are needed.
;; 9. Are there constitutional symptoms of bone disease?
;; 10. Describe the effects of the condition on the veteran's usual
;; occupation and daily activities.
;; 11. History of neoplasm.
;;
;; a. Date of diagnosis, diagnosis.
;; b. Benign or malignant.
;; c. Type of treatment, dates.
;; d. Last date of treatment.
;;
;;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. Follow JOINTS worksheet.
;; 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.?
;; 9. For genu recurvatum, acquired, traumatic: Is there weakness and
;; insecurity on weight-bearing?
;; 10. For malunion of os calcis or astralgus - degree of deformity (mild,
;; moderate, marked).
;;
;;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[HDVBCWB3 4155 printed Oct 16, 2024@17:50:43 Page 2
DVBCWB3 ;ALB/RLC BONES WKS TEXT - 1 ; 12 FEB 2007
+1 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. Describe details of any injury.
+8 ;; 2. For episodes of osteomyelitis, location, frequency. Is there current
+9 ;; active infection? If not, when was the last active infection?
+10 ;; 3. History of hospitalizations or surgery, reason or type of surgery,
+11 ;; location and dates, if known.
+12 ;; 4. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
+13 ;; drainage, instability or giving way, "locking," abnormal motion, etc.
+14 ;; 5. Hand dominance and how determined.
+15 ;; 6. Treatment: medication type, dose, frequency, response, and
+16 ;; side effects; other treatment.
+17 ;; 7. If there are periods of flare-up of bone disease:
+18 ;;
+19 ;; a. State their severity, frequency, and duration.
+20 ;; b. Name the precipitating and alleviating factors.
+21 ;; c. Estimate to what extent, if any, they affect functional
+22 ;; impairment during the flare-up.
+23 ;;
+24 ;; 8. Describe whether crutches, brace, cane, corrective shoes, etc.,
+25 ;; are needed.
+26 ;; 9. Are there constitutional symptoms of bone disease?
+27 ;; 10. Describe the effects of the condition on the veteran's usual
+28 ;; occupation and daily activities.
+29 ;; 11. History of neoplasm.
+30 ;;
+31 ;; a. Date of diagnosis, diagnosis.
+32 ;; b. Benign or malignant.
+33 ;; c. Type of treatment, dates.
+34 ;; d. Last date of treatment.
+35 ;;
+36 ;;C. Physical Examination (Objective Findings):
+37 ;;
+38 ;; Address each of the following as appropriate to the disability
+39 ;; being examined and fully describe current findings:
+40 ;;
+41 ;; 1. Describe objective evidence of deformity, angulation, false
+42 ;; motion, shortening, intra articular involvement, etc.
+43 ;; 2. Malunion, nonunion, any loose motion, false joint.
+44 ;; 3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
+45 ;; 4. For weight bearing joints (hip, knee, ankle), describe gait
+46 ;; and functional limitations on standing and walking. Describe
+47 ;; any callosities, breakdown, or unusual shoe wear pattern that
+48 ;; would indicate abnormal weight bearing.
+49 ;; 5. If ankylosis is present, describe the position of the bones
+50 ;; of the joint in relationship to one another (in degrees of
+51 ;; flexion, external rotation, etc.), and state whether the
+52 ;; ankylosis is stable and pain free.
+53 ;; 6. With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED
+54 ;; JOINT IS REQUIRED. Follow JOINTS worksheet.
+55 ;; 7. If shortening of the leg may be present, measure the leg
+56 ;; length from the anterior superior iliac spine to the medial
+57 ;; malleolus.
+58 ;; 8. Are there constitutional signs of bone disease - anemia,
+59 ;; weight loss, fever, debility, amyloid liver, etc.?
+60 ;; 9. For genu recurvatum, acquired, traumatic: Is there weakness and
+61 ;; insecurity on weight-bearing?
+62 ;; 10. For malunion of os calcis or astralgus - degree of deformity (mild,
+63 ;; moderate, marked).
+64 ;;
+65 ;;D. Diagnostic and Clinical Tests:
+66 ;;
+67 ;; 1. As indicated: X-rays, including special views or weight
+68 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
+69 ;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
+70 ;; arthritis of a joint requires X-ray confirmation. Once the
+71 ;; diagnosis has been confirmed in a joint, further X-rays of that
+72 ;; joint are not required.
+73 ;; 2. For osteomyelitis, state whether there is an involucrum,
+74 ;; sequestrum, or draining sinus.
+75 ;; 3. Include results of all diagnostic and clinical tests
+76 ;; conducted in the examination report.
+77 ;;
+78 ;;E. Diagnosis:
+79 ;;
+80 ;;
+81 ;;
+82 ;;Signature: Date:
+83 ;;END
