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Routine: DVBCWHT1

DVBCWHT1.m

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  1. DVBCWHT1 ;ALB/CMM HAND, THUMB, FINGERS WKS TEXT - 1 ; 6 MARCH 1997
  1. ;;2.7;AMIE;**12**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;;
  1. ;; Comment on:
  1. ;; 1. If there are periods of flare-up of joint disease:
  1. ;; a. State their severity, frequency, and duration.
  1. ;;
  1. ;;
  1. ;; b. Name the precipitating and alleviating factors.
  1. ;;
  1. ;;
  1. ;; c. Estimate to what extent, if any, they result in additional
  1. ;; limitation of motion or functional impairment during the flare-up.
  1. ;;
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; Address each of the following as appropriate to the condition being
  1. ;; examined and full describe current findings:
  1. ;; 1. Anatomical defects.
  1. ;;
  1. ;;
  1. ;; 2. Functional defects (motion of thumb and fingers should be
  1. ;; described as to how near, in inches, the tip of thumb can
  1. ;; approximate the fingers, or how near the tips of fingers can
  1. ;; approximate the median transverse fold of the palm.
  1. ;;
  1. ;;
  1. ;; 3. Grasping objects (strength and dexterity).
  1. ;;
  1. ;;
  1. ;;The hand should be evaluated as a unit intricately adapted for grasping,
  1. ;;pushing, pulling, twisting, probing, writing, touching, and expression.
  1. ;;Do not designate fingers numerically; use thumb, index, middle (or
  1. ;;long), ring, and little. Specify which hand is involved and state
  1. ;;whether the individual is right- or left-handed. Designate the joints
  1. ;;as wrist, MP (metacarpophalangeal), PIP (proximal interphalangeal), or
  1. ;;DIP (distal interphalangeal). Designate phalanges as proximal, middle
  1. ;;or distal.
  1. ;;
  1. ;;TOF
  1. ;; 4. A detailed assessment of each affected joint is required.
  1. ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
  1. ;; of motion, including movement against gravity and against
  1. ;; strong resistance.
  1. ;;
  1. ;;
  1. ;; b. State to what extent (if any) and in which degrees (if
  1. ;; possible) the range of motion or joint function is
  1. ;; ADDITIONALLY LIMITED by pain, fatigue, weakness, or lack
  1. ;; of endurance following repetitive use or during flare-ups.
  1. ;; If more than one of these is present, state, if possible,
  1. ;; which has the major functional impact.
  1. ;;
  1. ;;
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. Include results of all diagnostic and clinical tests conducte
  1. ;; in the examination report.
  1. ;;
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END