DVBCWNS1 ;ALB/CMM SPINE WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Present Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Complaints of pain, weakness, stiffness, fatigability, lack of
;; endurance, etc.
;;
;;
;; 2. Treatment - type, dose, frequency, response, side effects.
;;
;;
;; 3. If there are periods of flare-up:
;; 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.
;;
;;
;; 4. Describe whether crutches, brace, cane, etc., are needed.
;;
;;
;; 5. Describe details of any surgery or injury.
;;
;;
;; 6. Functional Assessment - Describe effects of the condition(s)
;; on the veteran's usual occupation and daily activities.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following as appropriate to the condition
;; being examined and fully describe current findings:
;; 1. Using a goniometer, measure the PASSIVE and ACTIVE range of
;; motion, including movement against gravity and against strong
;; resistance. Provide range of motion in degrees.
;;
;;
;; 2. If the spine is painful on motion, state at what point in the
;; range of motion pain begins and ends.
;;
;;
;; 3. State to what extent (if any) and in which degrees (if possible)
;; the range of motion or spinal 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.
;;
;;
;; 4. Describe objective evidence of painful motion, spasm, weakness,
;; tenderness, etc.
;;
;;
;; 5. Postural abnormalities, fixed deformity.
;;
;;
;; 6. Musculature of back.
;;
;;
;; 7. Neurological abnormalities - if present, see appropriate worksheet.
;;
;;
;;D. 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.
;;
;;
;;E. Diagnostic and Clinical Tests:
;;
;; Obtain the following and comment on them, as indicated:
;; 1. X-rays, MRI, as indicated.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;F. Diagnosis:
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWNS1 2936 printed Dec 13, 2024@01:52:48 Page 2
DVBCWNS1 ;ALB/CMM SPINE 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. Present Medical History (Subjective Complaints):
+6 ;;
+7 ;; Comment on:
+8 ;; 1. Complaints of pain, weakness, stiffness, fatigability, lack of
+9 ;; endurance, etc.
+10 ;;
+11 ;;
+12 ;; 2. Treatment - type, dose, frequency, response, side effects.
+13 ;;
+14 ;;
+15 ;; 3. If there are periods of flare-up:
+16 ;; a. State their severity, frequency, and duration.
+17 ;;
+18 ;;
+19 ;; b. Name the precipitating and alleviating factors.
+20 ;;
+21 ;;
+22 ;; c. Estimate to what extent, if any, they result in additional
+23 ;; limitation of motion or functional impairment during the
+24 ;; flare-up.
+25 ;;
+26 ;;
+27 ;; 4. Describe whether crutches, brace, cane, etc., are needed.
+28 ;;
+29 ;;
+30 ;; 5. Describe details of any surgery or injury.
+31 ;;
+32 ;;
+33 ;; 6. Functional Assessment - Describe effects of the condition(s)
+34 ;; on the veteran's usual occupation and daily activities.
+35 ;;
+36 ;;
+37 ;;C. Physical Examination (Objective Findings):
+38 ;;
+39 ;; Address each of the following as appropriate to the condition
+40 ;; being examined and fully describe current findings:
+41 ;; 1. Using a goniometer, measure the PASSIVE and ACTIVE range of
+42 ;; motion, including movement against gravity and against strong
+43 ;; resistance. Provide range of motion in degrees.
+44 ;;
+45 ;;
+46 ;; 2. If the spine is painful on motion, state at what point in the
+47 ;; range of motion pain begins and ends.
+48 ;;
+49 ;;
+50 ;; 3. State to what extent (if any) and in which degrees (if possible)
+51 ;; the range of motion or spinal function is ADDITIONALLY LIMITED
+52 ;; by pain, fatigue, weakness, or lack of endurance following
+53 ;; repetitive use or during flare-ups. If more than one of these
+54 ;; is present, state, if possible, which has the major functional
+55 ;; impact.
+56 ;;
+57 ;;
+58 ;; 4. Describe objective evidence of painful motion, spasm, weakness,
+59 ;; tenderness, etc.
+60 ;;
+61 ;;
+62 ;; 5. Postural abnormalities, fixed deformity.
+63 ;;
+64 ;;
+65 ;; 6. Musculature of back.
+66 ;;
+67 ;;
+68 ;; 7. Neurological abnormalities - if present, see appropriate worksheet.
+69 ;;
+70 ;;
+71 ;;D. Normal Range of Motion:
+72 ;;
+73 ;; All joint Range of Motion measurements must be made using a
+74 ;; GONIOMETER. Show each measured range of motion separately rather
+75 ;; than as a continuum.
+76 ;;
+77 ;;
+78 ;;E. Diagnostic and Clinical Tests:
+79 ;;
+80 ;; Obtain the following and comment on them, as indicated:
+81 ;; 1. X-rays, MRI, as indicated.
+82 ;; 2. Include results of all diagnostic and clinical tests conducted
+83 ;; in the examination report.
+84 ;;
+85 ;;
+86 ;;F. Diagnosis:
+87 ;;
+88 ;;
+89 ;;Signature: Date:
+90 ;;END
