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Routine: DVBCWSW3

DVBCWSW3.m

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  1. DVBCWSW3 ;ALB/CMM SCARS WKS TEXT - 1 ; 11/20/02 3:04pm
  1.  ;;2.7;AMIE;**49**;Apr 10, 1995
  1.  ;
  1.  ;
  1. TXT ;
  1.  ;;A.  Review of Medical Records:
  1.  ;;
  1.  ;;
  1.  ;;
  1.  ;;B.  Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;    1.  Type of injury or infection causing the wound or scar, its 
  1.  ;;        date, the treatment used, and the response to such treatment.
  1.  ;;
  1.  ;;
  1.  ;;    2.  Current symptoms.
  1.  ;;
  1.  ;;
  1.  ;;C.  Physical Examination (Objective Findings):
  1.  ;;
  1.  ;;    For every scar to be examined, address EACH of the following and
  1.  ;;    fully describe the current findings.  Note that, in addition
  1.  ;;    to measuring the scar itself, measurements of areas with certain
  1.  ;;    abnormal characteristics must also be provided.  All measurements
  1.  ;;    should be reported in inches or centimeters.
  1.  ;;    1.  Describe precise location of each scar.  Draw diagram if 
  1.  ;;        necessary.
  1.  ;;
  1.  ;;
  1.  ;;    2.  Give MEASUREMENT of length and width (at its widest part) of
  1.  ;;        each scar.
  1.  ;;
  1.  ;;
  1.  ;;    3.  Is there pain in the scar on examination?
  1.  ;;
  1.  ;;
  1.  ;;    4.  Is there adherence to underlying tissue?
  1.  ;;
  1.  ;;
  1.  ;;    5.  Texture of skin.  If irregular, atrophic, shiny, scaly, etc.,
  1.  ;;         give MEASUREMENT of length and width of area so affected.
  1.  ;;
  1.  ;;
  1.  ;;    6.  Is the scar unstable, meaning is there frequent loss of 
  1.  ;;        covering of skin over the scar, such as from ulceration or
  1.  ;;        breakdown of skin?
  1.  ;;
  1.  ;;
  1.  ;;    7.  Is there elevation or depression of the surface contour
  1.  ;;        of the scar on palpation?
  1.  ;;
  1.  ;;
  1.  ;;    8.  Is the scar superficial (meaning there is no underlying
  1.  ;;        soft tissue damage)?
  1.  ;;
  1.  ;;
  1.  ;;    9.  Is the scar deep (meaning there is underlying soft tissue
  1.  ;;        loss or damage)?  If yes, give MEASUREMENT of length and
  1.  ;;        width of underlying soft tissue damage.
  1.  ;;
  1.  ;;
  1.  ;;   10.  Describe any inflammation, edema, or keloid formation.
  1.  ;;
  1.  ;;
  1.  ;;   11.  Describe color of scar compared to normal areas of skin
  1.  ;;        (give MEASUREMENT of length and width of any hypopigmentation 
  1.  ;;        or hyperpigmentation). 
  1.  ;;
  1.  ;;
  1.  ;;   12.  For face, discuss whether there is gross distortion or 
  1.  ;;        asymmetry of any feature or set of paired features (nose,
  1.  ;;        chin, forehead, eyes (including eyelids), ears (auricles),
  1.  ;;        cheeks, lips).
  1.  ;;
  1.  ;;
  1.  ;;   13.  Is there an area of induration and inflexibility of skin in
  1.  ;;        the area of the scar?  If so, give MEASUREMENT of length
  1.  ;;        and width of area of induration.
  1.  ;;
  1.  ;;
  1.  ;;   14.  Describe any limitation of motion or other limitation of
  1.  ;;        function caused by a scar.
  1.  ;;
  1.  ;;
  1.  ;;   15.  With disfigurement or disfiguring scar of head, face, or
  1.  ;;        neck, submit COLOR PHOTOGRAPHS.
  1.  ;;        
  1.  ;;D.  Diagnostic and Clinical Tests:
  1.  ;;
  1.  ;;    Include results of all diagnostic and clinical tests conducted
  1.  ;;    in the examination report.
  1.  ;;
  1.  ;;
  1.  ;;E.  Diagnosis:
  1.  ;;
  1.  ;;
  1.  ;;Signature:                             Date:
  1.  ;;END