- DVBCWJW7 ;ALB/RLC JOINTS WKS TEXT - 1 ; 7 APRIL 2005
- ;;2.7;AMIE;**144**;FEB 17, 2004;Build 5
- ;
- ;
- TXT ;
- ;;A. Review of Medical Records:
- ;;
- ;;
- ;;B. Medical History (Subjective Complaints):
- ;;
- ;; Comment on:
- ;;
- ;; 1. Date, circumstances of onset, and course since onset.
- ;; 2. Pain, weakness, stiffness, deformity, instability or giving way,
- ;; "locking," weakness, lack of endurance, effusion, episodes of
- ;; dislocation or subluxation, etc.
- ;; 3. Signs of inflammation: swelling, heat, redness, tenderness or
- ;; drainage.
- ;; 4. Treatment - type, include dose for medication, frequency, response,
- ;; side effects.
- ;; 5. 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. State to what extent, if any, per veteran, they
- ;; result in additional limitation of motion or
- ;; functional impairment (e.g., pain, weakness, fatigue, speed,
- ;; or incoordination) during the flare-up.
- ;;
- ;; 6. Describe whether crutches, brace, cane, corrective shoes,
- ;; etc., are needed.
- ;; 7. Describe details of any hospitalizations, surgery or injury.
- ;; 8. For inflammatory arthritis, describe any constitutional
- ;; symptoms and number and duration of incapacitating exacerbations
- ;; per year.
- ;; 9. Describe the effects of the condition on the veteran's usual
- ;; occupation and daily activities.
- ;; 10. Describe functional limitations on standing and walking.
- ;; 11. Dominance of extremity and means used to identify dominant
- ;; extremity.
- ;; 12. If there is a prosthesis, provide date of prosthetic implant
- ;; and describe any complaint of pain, weakness, or limitation
- ;; of motion.
- ;; 13. History of neoplasm:
- ;;
- ;; a. Date of diagnosis, diagnosis.
- ;; b. Benign or malignant.
- ;; c. Type and date(s) of treatment.
- ;; d. Last date of treatment.
- ;;
- ;;
- ;;C. Physical Examination (Objective Findings):
- ;;
- ;; Address each of the following as appropriate to the condition
- ;; being examined and fully describe current findings: A DETAILED
- ;; ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED, INCLUDING JOINTS
- ;; WITH PROSTHESES.
- ;;
- ;; 1. Using a goniometer, measure the ACTIVE range of motion, of the
- ;; unaffected joint (if normal) than the affected. Provide range of
- ;; motion in degrees.
- ;; 2. Describe presence of objective evidence of pain in the affected
- ;; joint at rest and during active range of motion.
- ;; 3. Describe objective evidence of edema, effusion, instability,
- ;; tenderness, redness, heat, abnormal movement, guarding of movement,
- ;; deformity, malalignment, drainage, weakness, etc.
- ;; 4. For weight bearing joints (hip, knee, ankle), describe gait.
- ;; Describe any callosities, breakdown, or unusual shoe wear pattern
- ;; that would indicate abnormal weight bearing.
- ;; 5. If ankylosis is present, describe the position of the bones of
- ;; the joint in relationship to one another (in degrees of flexion,
- ;; external rotation, etc.), and state whether the ankylosis is
- ;; stable and pain free.
- ;; 6. If indicated, measure the leg length from the anterior
- ;; superior iliac spine to the medial malleolus.
- ;; 7. For INFLAMMATORY ARTHRITIS, describe any constitutional signs and
- ;; extra-articular manifestations (Follow appropriate worksheet for
- ;; required examination findings). State whether disease is active
- ;; and extent of overall impairment of health.
- ;; 8. Describe range of motion with prosthesis in same detail as described
- ;; above for nonprosthetic joints.
- ;;
- ;;
- ;;D. Loss of Joint Function with Use:
- ;;
- ;; Impairment of joint function is determine by range of joint motion as
- ;; reported in the physical examination and additional loss of range of
- ;; motion after repetitive use caused by the following factors:
- ;;
- ;; - Pain
- ;; - Fatigue
- ;; - Weakness
- ;; - Lack of endurance
- ;; - Incoordination
- ;;
- ;; Have the veteran move the affected joint/joints through repetitive active
- ;; range of motion, as tolerated (maximum of 3 repetitions). After
- ;; repetitive motion, re-measure the range of motion of the affected joint/
- ;; joints. Do any of the above factors cause any additional loss of range
- ;; of motion? If so, record the re-measured range of motion and the
- ;; predominant factor causing the change in motion.
- ;;
- ;; If repetitive active range of motion of a joint cannot be done, state
- ;; so and give the reason.
- ;;
- ;;
- ;;E. Normal Range of Motion: All joint Range of Motion measurements
- ;;must be made using a goniometer. Show each measured range of motion
- ;;separately rather than as a continuum. For example, if the veteran
- ;;lacks 10 degrees of full knee extension and has normal flexion, show
- ;;the range of motion as extension to minus 10 degrees (or lacks 10
- ;;degrees of extension) and flexion 10 to 140 degrees.
- ;;
- ;; 1. Hip range of motion: (Movement of femur as it rotates in the
- ;; acetabulum.)
- ;;
- ;; a. Normal range of motion, using the anatomical
- ;; position as zero degrees.
- ;;
- ;; Flexion = 0 to 125 degrees (To gain a true picture of hip
- ;; flexion, i.e., movement between the pelvis and femur in
- ;; the hip joint, the opposite thigh should be extended to
- ;; minimize motion between the pelvis and spine.)
- ;;
- ;; Extension = 0 to 30 degrees.
- ;;
- ;; Adduction = 0 to 25 degrees.
- ;;
- ;; Abduction = 0 to 45 degrees.
- ;;
- ;; External rotation = 0 to 60 degrees.
- ;;
- ;; Internal rotation = 0 to 40 degrees.
- ;;
- ;;
- ;; 2. Knee range of motion:
- ;;
- ;; a. Normal range of motion, using the anatomical
- ;; position as zero degrees.
- ;;
- ;; Flexion = 0 to 140 degrees.
- ;;
- ;; Extension - zero degrees = full extension. Show loss of
- ;; extension by describing the degrees in which extension is
- ;; not possible. (e.g., Show range of motion as extension to
- ;; minus 10 degrees and flexion 10 to 140 degrees when full
- ;; extension is limited by 10 degrees and full flexion is
- ;; possible.)
- ;;
- ;; b. Stability.
- ;;
- ;; Medial and Lateral Collateral Ligaments:
- ;; Varus/valgus in neutral and in 30 degrees of flexion -
- ;; normal is no motion.
- ;;
- ;; Anterior and Posterior Cruciate Ligaments:
- ;; Anterior/posterior in 30 degrees of flexion with
- ;; foot stabilized - normal is less than 5 mm. of motion
- ;; (1/4 inch - Lachman's test) or in 90 degrees of flexion
- ;; with foot stabilized - normal is less than 5mm. of motion
- ;; (1/4 inch - anterior and posterior drawer test).
- ;;
- ;; Medial and Lateral Meniscus: Perform McMurray's test.
- ;;
- ;;
- ;; 3. Ankle range of motion:
- ;;
- ;; a. Neutral position is with foot at 90 degrees to
- ;; ankle. From that position, dorsiflexion is 0 to 20
- ;; degrees; plantar flexion is 0 to 45 degrees.
- ;; b. Describe any varus or valgus angulation of the
- ;; os calcis in relationship to the long axis of the
- ;; tibia and fibula.
- ;;
- ;;
- ;; 4. Shoulder, elbow, forearm, and wrist range of motion:
- ;;
- ;; a. Normal range of motion is measured with zero degrees the
- ;; anatomical position except for 2 situations:
- ;;
- ;; i. Supination and pronation of the
- ;; forearm is measured with the arm
- ;; against the body, the elbow
- ;; flexed to 90 degrees, and the
- ;; forearm in mid position (zero
- ;; degrees) between supination and
- ;; pronation.
- ;; ii. Shoulder rotation is measured
- ;; with the arm abducted to 90
- ;; degrees, the elbow flexed to 90
- ;; degrees, and the forearm
- ;; reflecting the midpoint (zero
- ;; degrees) between internal and
- ;; external rotation of the shoulder.
- ;;
- ;; b. Shoulder forward flexion = zero to 180
- ;; degrees.
- ;; c. Shoulder abduction = zero to 180 degrees.
- ;; d. Shoulder external rotation = zero to 90
- ;; degrees.
- ;; e. Shoulder internal rotation = zero to 90
- ;; degrees.
- ;; f. Elbow flexion = zero to 145 degrees.
- ;; g. Forearm supination = zero to 85 degrees.
- ;; h. Forearm pronation = zero to 80 degrees.
- ;; i. Wrist dorsiflexion (extension) = zero to 70
- ;; degrees.
- ;; j. Wrist palmar flexion = zero to 80 degrees.
- ;; k. Wrist radial deviation = zero to 20 degrees.
- ;; l. Wrist ulnar deviation = zero to 45 degrees.
- ;;
- ;;
- ;;F. 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. Include results of all diagnostic and clinical tests in the
- ;; examination report.
- ;;
- ;;
- ;;G. Diagnosis:
- ;;
- ;; For subluxation or instability of the knee, indicate whether it is
- ;; slight, moderate or severe.
- ;;
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWJW7 10373 printed Feb 18, 2025@23:18:37 Page 2
- DVBCWJW7 ;ALB/RLC JOINTS WKS TEXT - 1 ; 7 APRIL 2005
- +1 ;;2.7;AMIE;**144**;FEB 17, 2004;Build 5
- +2 ;
- +3 ;
- TXT ;
- +1 ;;A. Review of Medical Records:
- +2 ;;
- +3 ;;
- +4 ;;B. Medical History (Subjective Complaints):
- +5 ;;
- +6 ;; Comment on:
- +7 ;;
- +8 ;; 1. Date, circumstances of onset, and course since onset.
- +9 ;; 2. Pain, weakness, stiffness, deformity, instability or giving way,
- +10 ;; "locking," weakness, lack of endurance, effusion, episodes of
- +11 ;; dislocation or subluxation, etc.
- +12 ;; 3. Signs of inflammation: swelling, heat, redness, tenderness or
- +13 ;; drainage.
- +14 ;; 4. Treatment - type, include dose for medication, frequency, response,
- +15 ;; side effects.
- +16 ;; 5. If there are periods of flare-up of joint disease:
- +17 ;;
- +18 ;; a. State their severity, frequency, and duration.
- +19 ;; b. Name the precipitating and alleviating factors.
- +20 ;; c. State to what extent, if any, per veteran, they
- +21 ;; result in additional limitation of motion or
- +22 ;; functional impairment (e.g., pain, weakness, fatigue, speed,
- +23 ;; or incoordination) during the flare-up.
- +24 ;;
- +25 ;; 6. Describe whether crutches, brace, cane, corrective shoes,
- +26 ;; etc., are needed.
- +27 ;; 7. Describe details of any hospitalizations, surgery or injury.
- +28 ;; 8. For inflammatory arthritis, describe any constitutional
- +29 ;; symptoms and number and duration of incapacitating exacerbations
- +30 ;; per year.
- +31 ;; 9. Describe the effects of the condition on the veteran's usual
- +32 ;; occupation and daily activities.
- +33 ;; 10. Describe functional limitations on standing and walking.
- +34 ;; 11. Dominance of extremity and means used to identify dominant
- +35 ;; extremity.
- +36 ;; 12. If there is a prosthesis, provide date of prosthetic implant
- +37 ;; and describe any complaint of pain, weakness, or limitation
- +38 ;; of motion.
- +39 ;; 13. History of neoplasm:
- +40 ;;
- +41 ;; a. Date of diagnosis, diagnosis.
- +42 ;; b. Benign or malignant.
- +43 ;; c. Type and date(s) of treatment.
- +44 ;; d. Last date of treatment.
- +45 ;;
- +46 ;;
- +47 ;;C. Physical Examination (Objective Findings):
- +48 ;;
- +49 ;; Address each of the following as appropriate to the condition
- +50 ;; being examined and fully describe current findings: A DETAILED
- +51 ;; ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED, INCLUDING JOINTS
- +52 ;; WITH PROSTHESES.
- +53 ;;
- +54 ;; 1. Using a goniometer, measure the ACTIVE range of motion, of the
- +55 ;; unaffected joint (if normal) than the affected. Provide range of
- +56 ;; motion in degrees.
- +57 ;; 2. Describe presence of objective evidence of pain in the affected
- +58 ;; joint at rest and during active range of motion.
- +59 ;; 3. Describe objective evidence of edema, effusion, instability,
- +60 ;; tenderness, redness, heat, abnormal movement, guarding of movement,
- +61 ;; deformity, malalignment, drainage, weakness, etc.
- +62 ;; 4. For weight bearing joints (hip, knee, ankle), describe gait.
- +63 ;; Describe any callosities, breakdown, or unusual shoe wear pattern
- +64 ;; that would indicate abnormal weight bearing.
- +65 ;; 5. If ankylosis is present, describe the position of the bones of
- +66 ;; the joint in relationship to one another (in degrees of flexion,
- +67 ;; external rotation, etc.), and state whether the ankylosis is
- +68 ;; stable and pain free.
- +69 ;; 6. If indicated, measure the leg length from the anterior
- +70 ;; superior iliac spine to the medial malleolus.
- +71 ;; 7. For INFLAMMATORY ARTHRITIS, describe any constitutional signs and
- +72 ;; extra-articular manifestations (Follow appropriate worksheet for
- +73 ;; required examination findings). State whether disease is active
- +74 ;; and extent of overall impairment of health.
- +75 ;; 8. Describe range of motion with prosthesis in same detail as described
- +76 ;; above for nonprosthetic joints.
- +77 ;;
- +78 ;;
- +79 ;;D. Loss of Joint Function with Use:
- +80 ;;
- +81 ;; Impairment of joint function is determine by range of joint motion as
- +82 ;; reported in the physical examination and additional loss of range of
- +83 ;; motion after repetitive use caused by the following factors:
- +84 ;;
- +85 ;; - Pain
- +86 ;; - Fatigue
- +87 ;; - Weakness
- +88 ;; - Lack of endurance
- +89 ;; - Incoordination
- +90 ;;
- +91 ;; Have the veteran move the affected joint/joints through repetitive active
- +92 ;; range of motion, as tolerated (maximum of 3 repetitions). After
- +93 ;; repetitive motion, re-measure the range of motion of the affected joint/
- +94 ;; joints. Do any of the above factors cause any additional loss of range
- +95 ;; of motion? If so, record the re-measured range of motion and the
- +96 ;; predominant factor causing the change in motion.
- +97 ;;
- +98 ;; If repetitive active range of motion of a joint cannot be done, state
- +99 ;; so and give the reason.
- +100 ;;
- +101 ;;
- +102 ;;E. Normal Range of Motion: All joint Range of Motion measurements
- +103 ;;must be made using a goniometer. Show each measured range of motion
- +104 ;;separately rather than as a continuum. For example, if the veteran
- +105 ;;lacks 10 degrees of full knee extension and has normal flexion, show
- +106 ;;the range of motion as extension to minus 10 degrees (or lacks 10
- +107 ;;degrees of extension) and flexion 10 to 140 degrees.
- +108 ;;
- +109 ;; 1. Hip range of motion: (Movement of femur as it rotates in the
- +110 ;; acetabulum.)
- +111 ;;
- +112 ;; a. Normal range of motion, using the anatomical
- +113 ;; position as zero degrees.
- +114 ;;
- +115 ;; Flexion = 0 to 125 degrees (To gain a true picture of hip
- +116 ;; flexion, i.e., movement between the pelvis and femur in
- +117 ;; the hip joint, the opposite thigh should be extended to
- +118 ;; minimize motion between the pelvis and spine.)
- +119 ;;
- +120 ;; Extension = 0 to 30 degrees.
- +121 ;;
- +122 ;; Adduction = 0 to 25 degrees.
- +123 ;;
- +124 ;; Abduction = 0 to 45 degrees.
- +125 ;;
- +126 ;; External rotation = 0 to 60 degrees.
- +127 ;;
- +128 ;; Internal rotation = 0 to 40 degrees.
- +129 ;;
- +130 ;;
- +131 ;; 2. Knee range of motion:
- +132 ;;
- +133 ;; a. Normal range of motion, using the anatomical
- +134 ;; position as zero degrees.
- +135 ;;
- +136 ;; Flexion = 0 to 140 degrees.
- +137 ;;
- +138 ;; Extension - zero degrees = full extension. Show loss of
- +139 ;; extension by describing the degrees in which extension is
- +140 ;; not possible. (e.g., Show range of motion as extension to
- +141 ;; minus 10 degrees and flexion 10 to 140 degrees when full
- +142 ;; extension is limited by 10 degrees and full flexion is
- +143 ;; possible.)
- +144 ;;
- +145 ;; b. Stability.
- +146 ;;
- +147 ;; Medial and Lateral Collateral Ligaments:
- +148 ;; Varus/valgus in neutral and in 30 degrees of flexion -
- +149 ;; normal is no motion.
- +150 ;;
- +151 ;; Anterior and Posterior Cruciate Ligaments:
- +152 ;; Anterior/posterior in 30 degrees of flexion with
- +153 ;; foot stabilized - normal is less than 5 mm. of motion
- +154 ;; (1/4 inch - Lachman's test) or in 90 degrees of flexion
- +155 ;; with foot stabilized - normal is less than 5mm. of motion
- +156 ;; (1/4 inch - anterior and posterior drawer test).
- +157 ;;
- +158 ;; Medial and Lateral Meniscus: Perform McMurray's test.
- +159 ;;
- +160 ;;
- +161 ;; 3. Ankle range of motion:
- +162 ;;
- +163 ;; a. Neutral position is with foot at 90 degrees to
- +164 ;; ankle. From that position, dorsiflexion is 0 to 20
- +165 ;; degrees; plantar flexion is 0 to 45 degrees.
- +166 ;; b. Describe any varus or valgus angulation of the
- +167 ;; os calcis in relationship to the long axis of the
- +168 ;; tibia and fibula.
- +169 ;;
- +170 ;;
- +171 ;; 4. Shoulder, elbow, forearm, and wrist range of motion:
- +172 ;;
- +173 ;; a. Normal range of motion is measured with zero degrees the
- +174 ;; anatomical position except for 2 situations:
- +175 ;;
- +176 ;; i. Supination and pronation of the
- +177 ;; forearm is measured with the arm
- +178 ;; against the body, the elbow
- +179 ;; flexed to 90 degrees, and the
- +180 ;; forearm in mid position (zero
- +181 ;; degrees) between supination and
- +182 ;; pronation.
- +183 ;; ii. Shoulder rotation is measured
- +184 ;; with the arm abducted to 90
- +185 ;; degrees, the elbow flexed to 90
- +186 ;; degrees, and the forearm
- +187 ;; reflecting the midpoint (zero
- +188 ;; degrees) between internal and
- +189 ;; external rotation of the shoulder.
- +190 ;;
- +191 ;; b. Shoulder forward flexion = zero to 180
- +192 ;; degrees.
- +193 ;; c. Shoulder abduction = zero to 180 degrees.
- +194 ;; d. Shoulder external rotation = zero to 90
- +195 ;; degrees.
- +196 ;; e. Shoulder internal rotation = zero to 90
- +197 ;; degrees.
- +198 ;; f. Elbow flexion = zero to 145 degrees.
- +199 ;; g. Forearm supination = zero to 85 degrees.
- +200 ;; h. Forearm pronation = zero to 80 degrees.
- +201 ;; i. Wrist dorsiflexion (extension) = zero to 70
- +202 ;; degrees.
- +203 ;; j. Wrist palmar flexion = zero to 80 degrees.
- +204 ;; k. Wrist radial deviation = zero to 20 degrees.
- +205 ;; l. Wrist ulnar deviation = zero to 45 degrees.
- +206 ;;
- +207 ;;
- +208 ;;F. Diagnostic and Clinical Tests:
- +209 ;;
- +210 ;; 1. As indicated: X-rays, including special views or weight
- +211 ;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
- +212 ;; NOTE: The diagnosis of degenerative arthritis or post-
- +213 ;; traumatic arthritis of a joint requires X-ray confirmation. Once
- +214 ;; the diagnosis has been confirmed in a joint, further X-rays of
- +215 ;; that joint are not required.
- +216 ;; 2. Include results of all diagnostic and clinical tests in the
- +217 ;; examination report.
- +218 ;;
- +219 ;;
- +220 ;;G. Diagnosis:
- +221 ;;
- +222 ;; For subluxation or instability of the knee, indicate whether it is
- +223 ;; slight, moderate or severe.
- +224 ;;
- +225 ;;
- +226 ;;
- +227 ;;Signature: Date:
- +228 ;;END