©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
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