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Routine: DVBCWNS5

DVBCWNS5.m

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  1. DVBCWNS5 ;VMP/JER - SPINE WKS TEXT - 1 ; 12/02/03 11:00am
  1. ;;2.7;AMIE;**60**;DEC 2, 2003
  1. ;
  1. TXT ;
  1. ;;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;B. Present Medical History (Subjective Complaints):
  1. ;;
  1. ;;Please comment whether etiology for any of these subjective complaints is
  1. ;;unrelated to claimed disability.
  1. ;;
  1. ;;1. Report complaints of pain (including any radiation), stiffness,
  1. ;; weakness, etc.
  1. ;; a. Onset
  1. ;; b. Location and distribution
  1. ;; c. Duration
  1. ;; d. Characteristics, quality, description
  1. ;; e. Intensity
  1. ;;2. Describe treatment - type, dose, frequency, response, side effects.
  1. ;;3. Report whether there are periods of flare-up. Provide the
  1. ;; following if individual reports periods of flare-up:
  1. ;; a. Severity, frequency, and duration.
  1. ;; b. Precipitating and alleviating factors.
  1. ;; c. Additional limitation of motion or functional impairment during
  1. ;; the flare-up.
  1. ;;4. Describe associated features or symptoms (e.g., weight loss, fevers,
  1. ;; malaise, dizziness, visual disturbances, numbness, weakness,
  1. ;; bladder complaints, bowel complaints, erectile dysfunction).
  1. ;;5. Describe walking and assistive devices.
  1. ;; a. Does the veteran walk unaided? Does the veteran use a cane,
  1. ;; crutches, or a walker?
  1. ;; b. Does the veteran use a brace (orthosis)?
  1. ;; c. How far and how long can the veteran walk?
  1. ;; d. Is the veteran unsteady? Does the veteran have a history of
  1. ;; falls?
  1. ;;6. Describe details of any trauma or injury, including dates, and direction
  1. ;; and magnitude of forces.
  1. ;;7. Describe details of any surgery, including dates.
  1. ;;8. Functional Assessment - Describe effects of the condition(s) on the
  1. ;; veteran's mobility (e.g., walking, transfers), activities of daily
  1. ;; living (i.e., eating, grooming, bathing, toileting, dressing), usual
  1. ;; occupation, recreational activities, driving.
  1. ;;
  1. ;;C. Physical Examination (Objective Findings): Address each of the following as
  1. ;; appropriate to the condition being examined and fully describe current
  1. ;; findings:
  1. ;;
  1. ;; 1. Inspection: spine, limbs, posture and gait, position of the
  1. ;; head, curvatures of the spine, symmetry in appearance, symmetry
  1. ;; and rhythm of spinal motion.
  1. ;;
  1. ;; 2. Range of motion
  1. ;;
  1. ;; a. Cervical Spine
  1. ;;
  1. ;; The reproducibility of an individual's range of motion is one
  1. ;; indicator of optimum effort. Pain, fear of injury, disuse or
  1. ;; neuromuscular inhibition may limit mobility by decreasing the
  1. ;; individual's effort. If range of motion measurements fail to
  1. ;; match known pathology, please repeat the measurements.
  1. ;; (Reference: Guides to the Evaluation of Permanent Impairment,
  1. ;; Fifth Edition, 2001, page 399).
  1. ;;
  1. ;; i. Using a goniometer, measure and report the range of motion in
  1. ;; degrees of forward flexion, extension, left lateral flexion,
  1. ;; right lateral flexion, left lateral rotation and right lateral
  1. ;; rotation. Generally, the normal ranges of motion for the
  1. ;; cervical spine are as follows:
  1. ;;
  1. ;; -Forward flexion: 0 to 45 degrees
  1. ;; -Extension: 0 to 45 degrees
  1. ;; -Left Lateral Flexion: 0 to 45 degrees
  1. ;; -Right Lateral Flexion: 0 to 45 degrees
  1. ;; -Left Lateral Rotation: 0 to 80 degrees
  1. ;; -Right Lateral Rotation: 0 to 80 degrees
  1. ;;
  1. ;; There may be a situation where an individual's range of motion is
  1. ;; reduced, but "normal" (in the examiner's opinion) based on the
  1. ;; individual's age, body habitus, neurologic disease, or other factors
  1. ;; unrelated to the disability for which the exam is being performed. In
  1. ;; this situation, please explain why the individual's measured range of
  1. ;; motion should be considered as "normal".
  1. ;;
  1. ;; ii. If the spine is painful on motion, state at what point in the
  1. ;; range of motion pain begins and ends.
  1. ;;
  1. ;; iii. State to what extent (if any), expressed in degrees if
  1. ;; possible, the range of motion is additionally limited by pain,
  1. ;; fatigue, weakness, or lack of endurance following repetitive use
  1. ;; or during flare-ups. If more than one of these is present,
  1. ;; state, if possible, which has the major functional impact.
  1. ;;
  1. ;; iv. Describe objective evidence of painful motion, spasm, weakness,
  1. ;; tenderness, etc.
  1. ;;
  1. ;; v. Describe any postural abnormalities, fixed deformity
  1. ;; (ankylosis), or abnormality of musculature of cervical spine
  1. ;; musculature. In the situation where there is unfavorable
  1. ;; ankylosis of the cervical spine, indicate whether there is:
  1. ;; difficulty walking because of a limited line of vision;
  1. ;; restricted opening of the mouth (with limited ability to
  1. ;; chew); breathing limited to diaphragmatic respiration;
  1. ;; gastrointestinal symptoms due to pressure of the costal margin
  1. ;; on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical
  1. ;; subluxation or dislocation
  1. ;;
  1. ;;
  1. ;; b. Thoracolumbar spine
  1. ;;
  1. ;; The reproducibility of an individual's range of motion is one
  1. ;; indicator of optimum effort. Pain, fear of injury, disuse or
  1. ;; neuromuscular inhibition may limit mobility by decreasing the
  1. ;; individual's effort. If range of motion measurements fail to
  1. ;; match known pathology, please repeat the measurements.
  1. ;; (Reference: Guides to the Evaluation of Permanent Impairment,
  1. ;; Fifth Edition, 2001, page 399).
  1. ;;
  1. ;; It is best to measure range of motion for the thoracolumbar
  1. ;; spine from a standing position. Measuring the range of motion
  1. ;; from a standing position (as opposed to from a sitting position)
  1. ;; will include the effects of forces generated by the distance
  1. ;; from the center of gravity from the axis of motion of the spine
  1. ;; and will include the effect of contraction of the spinal
  1. ;; muscles. Contraction of the spinal muscles imposes a significant
  1. ;; compressive force during spine movements upon the lumbar discs.
  1. ;;
  1. ;; i. Provide forward flexion of the thoracolumbar spine as a unit.
  1. ;; Do not include hip flexion. (See Magee, Orthopedic Physical
  1. ;; Assessment, Third Edition, 1997, W.B. Saunders Company,
  1. ;; pages 374-75). Using a goniometer, measure and report the range
  1. ;; of motion in degrees for forward flexion, extension, left
  1. ;; lateral flexion, right lateral flexion, left lateral rotation
  1. ;; and right lateral rotation. Generally, the normal ranges of
  1. ;; motion for the thoracolumbar spine as a unit are as follows:
  1. ;;
  1. ;; -Forward flexion: 0 to 90 degrees
  1. ;; -Extension: 0 to 30 degrees
  1. ;; -Left Lateral Flexion: 0 to 30 degrees
  1. ;; -Right Lateral Flexion: 0 to 30 degrees
  1. ;; -Left Lateral Rotation: 0 to 30 degrees
  1. ;; -Right Lateral Rotation: 0 to 30 degrees
  1. ;;
  1. ;;There may be a situation where an individual's range of motion is reduced, but
  1. ;;"normal" (in the examiner's opinion) based on the individual's age, body
  1. ;;habitus, neurologic disease, or other factors unrelated to the disability for
  1. ;;which the exam is being performed. In this situation, please explain why the
  1. ;;individual's measured range of motion should be considered as "normal".
  1. ;;
  1. ;; ii. If the spine is painful on motion, state at what point in the range
  1. ;; of motion pain begins and ends.
  1. ;;
  1. ;; iii. State to what extent (if any), expressed in degrees if possible,
  1. ;; the range of motion is additionally limited by pain, fatigue,
  1. ;; weakness, or lack of endurance following repetitive use or during
  1. ;; flare-ups. If more than one of these is present, state, if possible,
  1. ;; which has the major functional impact.
  1. ;;
  1. ;; iv. Describe objective evidence of painful motion, spasm, weakness,
  1. ;; tenderness, etc.
  1. ;;
  1. ;; a. Indicate whether there is muscle spasm, guarding or localized
  1. ;; tenderness with preserved spinal contour, and normal gait.
  1. ;;
  1. ;; b. Indicate whether there is muscle spasm, or guarding severe enough
  1. ;; to result in an abnormal gait, abnormal spinal contour such as
  1. ;; scoliosis, reversed lordosis or abnormal kyphosis.
  1. ;;
  1. ;; v. Describe any postural abnormalities, fixed deformity (ankylosis),
  1. ;; or abnormality of musculature of back. In the situation where
  1. ;; there is unfavorable ankylosis of the thoracolumbar spine,
  1. ;; indicate whether there is: difficulty walking because of a
  1. ;; limited line of vision; restricted opening of the mouth (with
  1. ;; limited ability to chew); breathing limited to diaphragmatic
  1. ;; respiration; gastrointestinal symptoms due to pressure of
  1. ;; the costal margin on the abdomen; dyspnea; dysphagia;
  1. ;; atlantoaxial or cervical subluxation or dislocation; or
  1. ;; neurologic symptoms due to nerve root involvement.
  1. ;;
  1. ;; 3. Neurological examination
  1. ;;
  1. ;;Please perform complete neurologic evaluation as indicated based upon
  1. ;;disability for which the exam is being performed. Please provide brief
  1. ;;statement if any of the following (a-e) is not included in exam. For
  1. ;;additional neurologic effects of disability not captured by a - e,
  1. ;;(e.g. bladder problems) please refer to appropriate worksheet for the body
  1. ;;system affected.
  1. ;;
  1. ;; a. Sensory examination, to include sacral segments.
  1. ;; b. Motor examination (atrophy, circumferential measurements, tone,
  1. ;; and strength).
  1. ;; c. Reflexes (deep tendon, cutaneous, and pathologic).
  1. ;; d. Rectal examination (sensation, tone, volitional control, and
  1. ;; reflexes).
  1. ;; e. Lasegue's sign.
  1. ;;
  1. ;; 4. For vertebral fractures, report the percentage of loss of
  1. ;; height, if any, of the vertebral body
  1. ;; 5. Non-organic physical signs (e.g., Waddell tests, others).
  1. ;;
  1. ;;D. For intervertebral disc syndrome
  1. ;;
  1. ;; 1. Conduct and report a separate history and physical
  1. ;; examination for each segment of the spine (cervical,
  1. ;; thoracic, lumbar) affected by disc disease.
  1. ;; 2. Conduct a complete history and physical examination of each
  1. ;; affected segment of the spine (cervical, thoracic, lumbar),
  1. ;; whether or not there has been surgery, as described above
  1. ;; under B. Present Medical History and C. Physical Examination.
  1. ;; 3. Conduct a thorough neurologic history and examination, as
  1. ;; described in C5, of all areas innervated by each affected
  1. ;; spinal segment. Specify the peripheral nerve(s) affected.
  1. ;; Include an evaluation of effects, if any, on bowel or bladder
  1. ;; functioning.
  1. ;; 4. Describe as precisely as possible, in number of days, the
  1. ;; duration of each incapacitating episode during the past
  1. ;; 12-month period. An incapacitating episode, for disability
  1. ;; evaluation purposes, is a period of acute signs and symptoms
  1. ;; due to intervertebral disc syndrome that requires bed rest
  1. ;; prescribed by a physician and treatment by a physician.
  1. ;;
  1. ;;E. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; 1. Imaging studies, when indicated.
  1. ;; 2. Electrodiagnostic tests, when indicated.
  1. ;; 3. Clinical laboratory tests, when indicated.
  1. ;; 4. Isotope scans, when indicated.
  1. ;; 5. Include results of all diagnostic and clinical tests conducted in the
  1. ;; examination report.
  1. ;;
  1. ;;F. Diagnosis:
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END