DVBCWHT1 ;ALB/CMM HAND, THUMB, FINGERS WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. If there are periods of flare-up of joint disease:
;; a. State their severity, frequency, and duration.
;;
;;
;; b. Name the precipitating and alleviating factors.
;;
;;
;; c. Estimate to what extent, if any, they result in additional
;; limitation of motion or functional impairment during the flare-up.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following as appropriate to the condition being
;; examined and full describe current findings:
;; 1. Anatomical defects.
;;
;;
;; 2. Functional defects (motion of thumb and fingers should be
;; described as to how near, in inches, the tip of thumb can
;; approximate the fingers, or how near the tips of fingers can
;; approximate the median transverse fold of the palm.
;;
;;
;; 3. Grasping objects (strength and dexterity).
;;
;;
;;The hand should be evaluated as a unit intricately adapted for grasping,
;;pushing, pulling, twisting, probing, writing, touching, and expression.
;;Do not designate fingers numerically; use thumb, index, middle (or
;;long), ring, and little. Specify which hand is involved and state
;;whether the individual is right- or left-handed. Designate the joints
;;as wrist, MP (metacarpophalangeal), PIP (proximal interphalangeal), or
;;DIP (distal interphalangeal). Designate phalanges as proximal, middle
;;or distal.
;;
;;TOF
;; 4. A detailed assessment of each affected joint is required.
;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
;; of motion, including movement against gravity and against
;; strong resistance.
;;
;;
;; b. State to what extent (if any) and in which degrees (if
;; possible) the range of motion or joint function is
;; ADDITIONALLY LIMITED by pain, fatigue, weakness, or lack
;; of endurance following repetitive use or during flare-ups.
;; If more than one of these is present, state, if possible,
;; which has the major functional impact.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Include results of all diagnostic and clinical tests conducte
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWHT1 2699 printed Dec 13, 2024@01:51:46 Page 2
DVBCWHT1 ;ALB/CMM HAND, THUMB, FINGERS WKS TEXT - 1 ; 6 MARCH 1997
+1 ;;2.7;AMIE;**12**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;
+4 ;;
+5 ;;B. Medical History (Subjective Complaints):
+6 ;;
+7 ;; Comment on:
+8 ;; 1. If there are periods of flare-up of joint disease:
+9 ;; a. State their severity, frequency, and duration.
+10 ;;
+11 ;;
+12 ;; b. Name the precipitating and alleviating factors.
+13 ;;
+14 ;;
+15 ;; c. Estimate to what extent, if any, they result in additional
+16 ;; limitation of motion or functional impairment during the flare-up.
+17 ;;
+18 ;;
+19 ;;C. Physical Examination (Objective Findings):
+20 ;;
+21 ;; Address each of the following as appropriate to the condition being
+22 ;; examined and full describe current findings:
+23 ;; 1. Anatomical defects.
+24 ;;
+25 ;;
+26 ;; 2. Functional defects (motion of thumb and fingers should be
+27 ;; described as to how near, in inches, the tip of thumb can
+28 ;; approximate the fingers, or how near the tips of fingers can
+29 ;; approximate the median transverse fold of the palm.
+30 ;;
+31 ;;
+32 ;; 3. Grasping objects (strength and dexterity).
+33 ;;
+34 ;;
+35 ;;The hand should be evaluated as a unit intricately adapted for grasping,
+36 ;;pushing, pulling, twisting, probing, writing, touching, and expression.
+37 ;;Do not designate fingers numerically; use thumb, index, middle (or
+38 ;;long), ring, and little. Specify which hand is involved and state
+39 ;;whether the individual is right- or left-handed. Designate the joints
+40 ;;as wrist, MP (metacarpophalangeal), PIP (proximal interphalangeal), or
+41 ;;DIP (distal interphalangeal). Designate phalanges as proximal, middle
+42 ;;or distal.
+43 ;;
+44 ;;TOF
+45 ;; 4. A detailed assessment of each affected joint is required.
+46 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
+47 ;; of motion, including movement against gravity and against
+48 ;; strong resistance.
+49 ;;
+50 ;;
+51 ;; b. State to what extent (if any) and in which degrees (if
+52 ;; possible) the range of motion or joint function is
+53 ;; ADDITIONALLY LIMITED by pain, fatigue, weakness, or lack
+54 ;; of endurance following repetitive use or during flare-ups.
+55 ;; If more than one of these is present, state, if possible,
+56 ;; which has the major functional impact.
+57 ;;
+58 ;;
+59 ;;D. Diagnostic and Clinical Tests:
+60 ;;
+61 ;; 1. Include results of all diagnostic and clinical tests conducte
+62 ;; in the examination report.
+63 ;;
+64 ;;
+65 ;;E. Diagnosis:
+66 ;;
+67 ;;
+68 ;;Signature: Date:
+69 ;;END
