DVBCWNS3 ;BPOIFO/ESW - SPINE WKS TEXT - 1 ; 10/8/02 10:52am
;;2.7;AMIE;**46**;Apr 10, 1995
;Per VHA Directive 10-92-142, this routine should not be modified
;
TXT ;
;;
;;A. Review of Medical Records: Report whether done or not.
;;
;;
;;B. Present Medical History (Subjective Complaints):
;;
;; 1. Report complaints of pain (including any radiation), stiffness,
;; weakness, etc.
;; a. Onset
;; b. Location and distribution
;; c. Duration
;; d. Characteristics, quality, description
;; e. Intensity
;; 2. Describe 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. Describe any additional limitation of motion or functional
;; impairment during the flare-up.
;; 4. Describe associated features or symptoms (e.g., weight loss, fevers,
;; malaise, dizziness, visual disturbances, numbness, weakness, bladder
;; complaints, bowel complaints, erectile dysfunction).
;; 5. Describe walking and assistive devices.
;; a. Walk unaided? Use of a cane, crutches, walker?
;; b. Use of orthosis (brace)?
;; c. How far and how long can the veteran walk?
;; d. Unsteadiness? Falls?
;; 6. Describe details of any trauma or injury, including dates,
;; and direction and magnitude of forces.
;; 7. Describe details of any surgery, including dates.
;; 8. Functional Assessment - Describe effects of the condition(s) on
;; the veteran's mobility (e.g., walking, transfers, bed activities),
;; activities of daily living (i.e., eating, grooming, bathing,
;; toileting, dressing), usual occupation, recreational activities,
;; driving.
;;
;;C. Physical Examination (Objective Findings):
;;
;;Address each of the following as appropriate to the condition being examined and
;;fully describe current findings:
;; 1. Inspection: spine, limbs, posture and gait, position of the head,
;; curvatures of the spine, symmetry in appearance, symmetry and rhythm of
;; spinal motion.
;; 2. Range of motion
;; a. Using a goniometer, measure the range of motion, and show
;; each measured range of motion (flexion, extension, etc.)
;; separately rather than as a continuum. Measure active range of
;; motion, and passive range of motion if active range of motion
;; is not normal.
;; b. State the normal range of motion when providing spine range
;; of motion. For example, state forward flexion of the lumbar spine
;; is 80 out of 90 degrees, and backward extension is 20 out of 35
;; degrees. (See Chapter 11 of Clinician's Guide for more detailed
;; discussion of spine range of motion.)
;; c. If the range of motion is affected by factors other than
;; spinal injury or disease, such as the claimant's body habitus,
;; provide an estimated normal range of motion for that particular
;; individual.
;; d. If the spine is painful on motion, state at what point in
;; the range of motion pain begins and ends.
;; e. State to what extent (if any), expressed in degrees if
;; possible, the range of motion is a d d i t i o n a l l y
;; l i m i t e d by pain, fatigue, weakness, or lack of endurance
;; following repetitive use or during flare-ups.
;; If more than one of these
;; If more than one of these is present, state, if possible, which
;; has the major functional impact.
;; 3. Describe objective evidence of painful motion, spasm, weakness,
;; tenderness, etc.
;; 4. Describe any postural abnormalities, fixed deformity (ankylosis), or
;; abnormality of musculature of back.
;; 5. Neurological examination
;; a. Sensory examination, to include sacral segments.
;; b. Motor examination (atrophy, circumferential measurements, tone,
;; and strength).
;; c. Reflexes (deep tendon, cutaneous, and pathologic).
;; d. Rectal examination (sensation, tone, volitional control,
;; and reflexes).
;; e. Lasegue's sign.
;; f. If the neurologic effects are not encompassed by this part
;; of the examination (e.g., if there are bladder problems),
;; follow appropriate worksheet for the body system affected.
;; 6. For vertebral fractures, report the percentage of loss of height, if any,
;; of the vertebral body.
;; 7. Non-organic physical signs (e.g., Waddell tests, others).
;;
;;D. For intervertebral disc syndrome
;;
;; 1. Conduct and report a separate history and physical examination for
;; each segment of the spine (cervical, thoracic, lumbar) affected by
;; disc disease.
;; 2. Conduct a complete history and physical examination of each affected
;; spinal segment, whether or not there has been surgery, as described
;; above under B and C.
;; 3. Conduct a thorough neurologic history and examination, as described
;; in C5, of all areas innervated by each affected spinal segment.
;; Specify the peripheral nerve(s) affected. Include an evaluation of
;; effects, if any, on bowel or bladder functioning.
;; 4. Describe as precisely as possible, in number of days, the duration
;; of each incapacitating episode during the past 12-month period.
;; An incapacitating episode, for disability evaluation purposes,
;; is a period of acute signs and symptoms due to intervertebral disk
;; syndrome that requires bed rest prescribed by a physician and
;; treatment by a physician.
;;
;;E. Diagnostic and Clinical Tests:
;;
;; 1. Imaging studies, when indicated.
;; 2. Electrodiagnostic tests, when indicated.
;; 3. Clinical laboratory tests, when indicated.
;; 4. Isotope scans, when indicated.
;; 5. 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[HDVBCWNS3 6599 printed Dec 13, 2024@01:52:50 Page 2
DVBCWNS3 ;BPOIFO/ESW - SPINE WKS TEXT - 1 ; 10/8/02 10:52am
+1 ;;2.7;AMIE;**46**;Apr 10, 1995
+2 ;Per VHA Directive 10-92-142, this routine should not be modified
+3 ;
TXT ;
+1 ;;
+2 ;;A. Review of Medical Records: Report whether done or not.
+3 ;;
+4 ;;
+5 ;;B. Present Medical History (Subjective Complaints):
+6 ;;
+7 ;; 1. Report complaints of pain (including any radiation), stiffness,
+8 ;; weakness, etc.
+9 ;; a. Onset
+10 ;; b. Location and distribution
+11 ;; c. Duration
+12 ;; d. Characteristics, quality, description
+13 ;; e. Intensity
+14 ;; 2. Describe treatment - type, dose, frequency, response, side effects.
+15 ;; 3. If there are periods of flare-up:
+16 ;; a. State their severity, frequency, and duration.
+17 ;; b. Name the precipitating and alleviating factors.
+18 ;; c. Describe any additional limitation of motion or functional
+19 ;; impairment during the flare-up.
+20 ;; 4. Describe associated features or symptoms (e.g., weight loss, fevers,
+21 ;; malaise, dizziness, visual disturbances, numbness, weakness, bladder
+22 ;; complaints, bowel complaints, erectile dysfunction).
+23 ;; 5. Describe walking and assistive devices.
+24 ;; a. Walk unaided? Use of a cane, crutches, walker?
+25 ;; b. Use of orthosis (brace)?
+26 ;; c. How far and how long can the veteran walk?
+27 ;; d. Unsteadiness? Falls?
+28 ;; 6. Describe details of any trauma or injury, including dates,
+29 ;; and direction and magnitude of forces.
+30 ;; 7. Describe details of any surgery, including dates.
+31 ;; 8. Functional Assessment - Describe effects of the condition(s) on
+32 ;; the veteran's mobility (e.g., walking, transfers, bed activities),
+33 ;; activities of daily living (i.e., eating, grooming, bathing,
+34 ;; toileting, dressing), usual occupation, recreational activities,
+35 ;; driving.
+36 ;;
+37 ;;C. Physical Examination (Objective Findings):
+38 ;;
+39 ;;Address each of the following as appropriate to the condition being examined and
+40 ;;fully describe current findings:
+41 ;; 1. Inspection: spine, limbs, posture and gait, position of the head,
+42 ;; curvatures of the spine, symmetry in appearance, symmetry and rhythm of
+43 ;; spinal motion.
+44 ;; 2. Range of motion
+45 ;; a. Using a goniometer, measure the range of motion, and show
+46 ;; each measured range of motion (flexion, extension, etc.)
+47 ;; separately rather than as a continuum. Measure active range of
+48 ;; motion, and passive range of motion if active range of motion
+49 ;; is not normal.
+50 ;; b. State the normal range of motion when providing spine range
+51 ;; of motion. For example, state forward flexion of the lumbar spine
+52 ;; is 80 out of 90 degrees, and backward extension is 20 out of 35
+53 ;; degrees. (See Chapter 11 of Clinician's Guide for more detailed
+54 ;; discussion of spine range of motion.)
+55 ;; c. If the range of motion is affected by factors other than
+56 ;; spinal injury or disease, such as the claimant's body habitus,
+57 ;; provide an estimated normal range of motion for that particular
+58 ;; individual.
+59 ;; d. If the spine is painful on motion, state at what point in
+60 ;; the range of motion pain begins and ends.
+61 ;; e. State to what extent (if any), expressed in degrees if
+62 ;; possible, the range of motion is a d d i t i o n a l l y
+63 ;; l i m i t e d by pain, fatigue, weakness, or lack of endurance
+64 ;; following repetitive use or during flare-ups.
+65 ;; If more than one of these
+66 ;; If more than one of these is present, state, if possible, which
+67 ;; has the major functional impact.
+68 ;; 3. Describe objective evidence of painful motion, spasm, weakness,
+69 ;; tenderness, etc.
+70 ;; 4. Describe any postural abnormalities, fixed deformity (ankylosis), or
+71 ;; abnormality of musculature of back.
+72 ;; 5. Neurological examination
+73 ;; a. Sensory examination, to include sacral segments.
+74 ;; b. Motor examination (atrophy, circumferential measurements, tone,
+75 ;; and strength).
+76 ;; c. Reflexes (deep tendon, cutaneous, and pathologic).
+77 ;; d. Rectal examination (sensation, tone, volitional control,
+78 ;; and reflexes).
+79 ;; e. Lasegue's sign.
+80 ;; f. If the neurologic effects are not encompassed by this part
+81 ;; of the examination (e.g., if there are bladder problems),
+82 ;; follow appropriate worksheet for the body system affected.
+83 ;; 6. For vertebral fractures, report the percentage of loss of height, if any,
+84 ;; of the vertebral body.
+85 ;; 7. Non-organic physical signs (e.g., Waddell tests, others).
+86 ;;
+87 ;;D. For intervertebral disc syndrome
+88 ;;
+89 ;; 1. Conduct and report a separate history and physical examination for
+90 ;; each segment of the spine (cervical, thoracic, lumbar) affected by
+91 ;; disc disease.
+92 ;; 2. Conduct a complete history and physical examination of each affected
+93 ;; spinal segment, whether or not there has been surgery, as described
+94 ;; above under B and C.
+95 ;; 3. Conduct a thorough neurologic history and examination, as described
+96 ;; in C5, of all areas innervated by each affected spinal segment.
+97 ;; Specify the peripheral nerve(s) affected. Include an evaluation of
+98 ;; effects, if any, on bowel or bladder functioning.
+99 ;; 4. Describe as precisely as possible, in number of days, the duration
+100 ;; of each incapacitating episode during the past 12-month period.
+101 ;; An incapacitating episode, for disability evaluation purposes,
+102 ;; is a period of acute signs and symptoms due to intervertebral disk
+103 ;; syndrome that requires bed rest prescribed by a physician and
+104 ;; treatment by a physician.
+105 ;;
+106 ;;E. Diagnostic and Clinical Tests:
+107 ;;
+108 ;; 1. Imaging studies, when indicated.
+109 ;; 2. Electrodiagnostic tests, when indicated.
+110 ;; 3. Clinical laboratory tests, when indicated.
+111 ;; 4. Isotope scans, when indicated.
+112 ;; 5. Include results of all diagnostic and clinical tests conducted
+113 ;; in the examination report.
+114 ;;
+115 ;;F. Diagnosis:
+116 ;;
+117 ;;
+118 ;;Signature: Date:
+119 ;;END
