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Routine: DVBCWB5

DVBCWB5.m

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  1. DVBCWB5 ;ALB/RLC BONES WKS TEXT - 1 ; 12 FEB 2007
  1.  ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8
  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 date of onset, circumstances, and initial manifestations of
  1.  ;;        the disease or injury.  Report course of condition.
  1.  ;;    2.  For osteomyelitis:  location(s), frequency and dates of episodes of
  1.  ;;        active infection.  Were there constitutional symptoms with episodes of
  1.  ;;        active infection?  Is there current active infection?  If not, name
  1.  ;;        year of last active infection and how the infection was confirmed.
  1.  ;;    3.  History of hospitalizations or surgery, reason or type of surgery,
  1.  ;;        location and dates, if known.
  1.  ;;    4.  Symptoms of pain (location), weakness, stiffness, swelling, heat,
  1.  ;;        redness, drainage, fever, debility, instability or giving way,
  1.  ;;        "locking," abnormal motion, etc.  If motion of a joint is affected,
  1.  ;;        follow the JOINTS examination worksheet.       
  1.  ;;    5.  Hand dominance and how determined.
  1.  ;;    6.  Describe current treatment:  type, response, and side effects.
  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, per veteran, they affect
  1.  ;;            functional impairment during the flare-up.
  1.  ;;
  1.  ;;    8.  Describe whether crutches, brace, cane, walker, etc., are needed
  1.  ;;        to assist walking.
  1.  ;;    9.  History of neoplasm.
  1.  ;;
  1.  ;;        a.  Date of diagnosis, exact 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, loss of a
  1.  ;;         bone or part of a bone, malunion, nonunion, loose motion, false
  1.  ;;         joint, etc.
  1.  ;;     2.  For infection, describe tenderness, drainage, edema, effusion,
  1.  ;;         painful motion, intra-articular involvement, weakness, redness, heat.
  1.  ;;     3.  With joint involvement, a detailed assessment of each affected joint
  1.  ;;         is required.  Follow the JOINTS worksheet.
  1.  ;;     4.  For weight bearing joints (hip, knee, ankle), describe gait
  1.  ;;         and functional limitations on standing (in minutes or hours) and
  1.  ;;         walking (in yards or miles).  Describe any callosities, areas of
  1.  ;;         breakdown, or unusual shoe wear pattern that would indicate abnormal
  1.  ;;         weight bearing.
  1.  ;;     5.  If ankylosis is present, follow the JOINTS worksheet.
  1.  ;;     6.  If shortening of the leg may be present, measure the leg length
  1.  ;;         bilaterally from the anterior superior iliac spine to the medial
  1.  ;;         malleolus.
  1.  ;;     7.  Are there constitutional signs of bone disease - anemia, weight loss,
  1.  ;;         fever, debility, amyloid liver, etc.?
  1.  ;;     8.  For genu recurvatum, acquired, traumatic:  Is there objective evidence
  1.  ;;         of weakness and insecurity on weight-bearing?
  1.  ;;     9.  For malunion of os calcis or astralgus - state degree of deformity
  1.  ;;         (mild, moderate, marked).
  1.  ;;     10. For a bone neoplasm, describe residuals of the neoplasm and its
  1.  ;;         treatment.
  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 presence and location of any 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.  Describe the effects of the condition on the veteran's usual
  1.  ;;         occupation and daily activities.
  1.  ;;
  1.  ;;
  1.  ;;Signature:                                   Date:
  1.  ;;END