DVBCWB5 ;ALB/RLC BONES WKS TEXT - 1 ; 12 FEB 2007
;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;;
;; 1. Describe date of onset, circumstances, and initial manifestations of
;; the disease or injury. Report course of condition.
;; 2. For osteomyelitis: location(s), frequency and dates of episodes of
;; active infection. Were there constitutional symptoms with episodes of
;; active infection? Is there current active infection? If not, name
;; year of last active infection and how the infection was confirmed.
;; 3. History of hospitalizations or surgery, reason or type of surgery,
;; location and dates, if known.
;; 4. Symptoms of pain (location), weakness, stiffness, swelling, heat,
;; redness, drainage, fever, debility, instability or giving way,
;; "locking," abnormal motion, etc. If motion of a joint is affected,
;; follow the JOINTS examination worksheet.
;; 5. Hand dominance and how determined.
;; 6. Describe current treatment: type, response, and side effects.
;; 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, per veteran, they affect
;; functional impairment during the flare-up.
;;
;; 8. Describe whether crutches, brace, cane, walker, etc., are needed
;; to assist walking.
;; 9. History of neoplasm.
;;
;; a. Date of diagnosis, exact 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, loss of a
;; bone or part of a bone, malunion, nonunion, loose motion, false
;; joint, etc.
;; 2. For infection, describe tenderness, drainage, edema, effusion,
;; painful motion, intra-articular involvement, weakness, redness, heat.
;; 3. With joint involvement, a detailed assessment of each affected joint
;; is required. Follow the JOINTS worksheet.
;; 4. For weight bearing joints (hip, knee, ankle), describe gait
;; and functional limitations on standing (in minutes or hours) and
;; walking (in yards or miles). Describe any callosities, areas of
;; breakdown, or unusual shoe wear pattern that would indicate abnormal
;; weight bearing.
;; 5. If ankylosis is present, follow the JOINTS worksheet.
;; 6. If shortening of the leg may be present, measure the leg length
;; bilaterally from the anterior superior iliac spine to the medial
;; malleolus.
;; 7. Are there constitutional signs of bone disease - anemia, weight loss,
;; fever, debility, amyloid liver, etc.?
;; 8. For genu recurvatum, acquired, traumatic: Is there objective evidence
;; of weakness and insecurity on weight-bearing?
;; 9. For malunion of os calcis or astralgus - state degree of deformity
;; (mild, moderate, marked).
;; 10. For a bone neoplasm, describe residuals of the neoplasm and its
;; treatment.
;;
;;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 presence and location of any involucrum,
;; sequestrum, or draining sinus.
;; 3. Include results of all diagnostic and clinical tests
;; conducted in the examination report.
;;
;;E. Diagnosis:
;;
;; 1. Describe the effects of the condition on the veteran's usual
;; occupation and daily activities.
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWB5 4559 printed Apr 09, 2024@20:45:12 Page 2
DVBCWB5 ;ALB/RLC BONES WKS TEXT - 1 ; 12 FEB 2007
+1 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;;
+5 ;; Comment on:
+6 ;;
+7 ;; 1. Describe date of onset, circumstances, and initial manifestations of
+8 ;; the disease or injury. Report course of condition.
+9 ;; 2. For osteomyelitis: location(s), frequency and dates of episodes of
+10 ;; active infection. Were there constitutional symptoms with episodes of
+11 ;; active infection? Is there current active infection? If not, name
+12 ;; year of last active infection and how the infection was confirmed.
+13 ;; 3. History of hospitalizations or surgery, reason or type of surgery,
+14 ;; location and dates, if known.
+15 ;; 4. Symptoms of pain (location), weakness, stiffness, swelling, heat,
+16 ;; redness, drainage, fever, debility, instability or giving way,
+17 ;; "locking," abnormal motion, etc. If motion of a joint is affected,
+18 ;; follow the JOINTS examination worksheet.
+19 ;; 5. Hand dominance and how determined.
+20 ;; 6. Describe current treatment: type, response, and side effects.
+21 ;; 7. If there are periods of flare-up of bone disease:
+22 ;;
+23 ;; a. State their severity, frequency, and duration.
+24 ;; b. Name the precipitating and alleviating factors.
+25 ;; c. Estimate to what extent, if any, per veteran, they affect
+26 ;; functional impairment during the flare-up.
+27 ;;
+28 ;; 8. Describe whether crutches, brace, cane, walker, etc., are needed
+29 ;; to assist walking.
+30 ;; 9. History of neoplasm.
+31 ;;
+32 ;; a. Date of diagnosis, exact diagnosis.
+33 ;; b. Benign or malignant.
+34 ;; c. Type of treatment, dates.
+35 ;; d. Last date of treatment.
+36 ;;
+37 ;;C. Physical Examination (Objective Findings):
+38 ;;
+39 ;; Address each of the following as appropriate to the disability
+40 ;; being examined and fully describe current findings:
+41 ;;
+42 ;; 1. Describe objective evidence of deformity, angulation, loss of a
+43 ;; bone or part of a bone, malunion, nonunion, loose motion, false
+44 ;; joint, etc.
+45 ;; 2. For infection, describe tenderness, drainage, edema, effusion,
+46 ;; painful motion, intra-articular involvement, weakness, redness, heat.
+47 ;; 3. With joint involvement, a detailed assessment of each affected joint
+48 ;; is required. Follow the JOINTS worksheet.
+49 ;; 4. For weight bearing joints (hip, knee, ankle), describe gait
+50 ;; and functional limitations on standing (in minutes or hours) and
+51 ;; walking (in yards or miles). Describe any callosities, areas of
+52 ;; breakdown, or unusual shoe wear pattern that would indicate abnormal
+53 ;; weight bearing.
+54 ;; 5. If ankylosis is present, follow the JOINTS worksheet.
+55 ;; 6. If shortening of the leg may be present, measure the leg length
+56 ;; bilaterally from the anterior superior iliac spine to the medial
+57 ;; malleolus.
+58 ;; 7. Are there constitutional signs of bone disease - anemia, weight loss,
+59 ;; fever, debility, amyloid liver, etc.?
+60 ;; 8. For genu recurvatum, acquired, traumatic: Is there objective evidence
+61 ;; of weakness and insecurity on weight-bearing?
+62 ;; 9. For malunion of os calcis or astralgus - state degree of deformity
+63 ;; (mild, moderate, marked).
+64 ;; 10. For a bone neoplasm, describe residuals of the neoplasm and its
+65 ;; treatment.
+66 ;;
+67 ;;D. Diagnostic and Clinical Tests:
+68 ;;
+69 ;; 1. As indicated: X-rays, including special views or weight
+70 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
+71 ;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
+72 ;; arthritis of a joint requires X-ray confirmation. Once the
+73 ;; diagnosis has been confirmed in a joint, further X-rays of that
+74 ;; joint are not required.
+75 ;; 2. For osteomyelitis, state presence and location of any involucrum,
+76 ;; sequestrum, or draining sinus.
+77 ;; 3. Include results of all diagnostic and clinical tests
+78 ;; conducted in the examination report.
+79 ;;
+80 ;;E. Diagnosis:
+81 ;;
+82 ;; 1. Describe the effects of the condition on the veteran's usual
+83 ;; occupation and daily activities.
+84 ;;
+85 ;;
+86 ;;Signature: Date:
+87 ;;END
