188 lines
8.3 KiB
Mathematica
188 lines
8.3 KiB
Mathematica
DVBCWJW3 ;ALB/CMM JOINTS WKS TEXT - 1 ; 6 MARCH 1997
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;;2.7;AMIE;**63**;FEB 17, 2004
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TXT ;
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;;A. Review of Medical Records:
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;;
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;;
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;;
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;;B. Medical History (Subjective Complaints):
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;;
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;; Comment on:
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;;
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;; 1. Pain, weakness, stiffness, swelling, heat and redness,
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;; instability or giving way, "locking," fatigability, lack of
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;; endurance, etc.
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;; 2. Treatment - type, dose, frequency, response, side effects.
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;; 3. If there are periods of flare-up of joint disease:
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;;
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;; a. State their severity, frequency, and duration.
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;; b. Name the precipitating and alleviating factors.
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;; c. State to what extent, if any, they result in additional
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;; limitation of motion or functional impairment during the
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;; flare-up.
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;;
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;; 4. Describe whether crutches, brace, cane, corrective shoes, etc.,
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;; are needed.
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;; 5. Describe details of any surgery or injury.
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;; 6. Describe any episodes of dislocation or recurrent subluxation.
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;; 7. For inflammatory arthritis, describe any constitutional symptoms.
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;; 8. Describe the effects of the condition on the veteran's usual
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;; occupation and daily activities.
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;; 9. Dominance of extremity and means used to identify dominant extremity
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;; 10. If there is a prosthesis, provide date of prosthetic implant
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;; and describe any complaint of pain, weakness, or limitation of
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;; motion. State whether crutches, brace, etc., are needed.
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;;
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;;
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;;C. Physical Examination (Objective Findings):
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;;
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;; Address each of the following as appropriate to the condition
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;; being examined and fully describe current findings: A DETAILED
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;; ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED, INCLUDING JOINTS
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;; WITH PROSTHESES.
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;;
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;; 1. Using a goniometer, measure the PASSIVE and ACTIVE range of
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;; motion, including movement against gravity and against strong
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;; resistance. Provide range of motion in degrees.
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;; 2. If the joint is painful on motion, state at what point in the
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;; range of motion pain begins and ends.
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;; 3. State to what extent (if any) and in which degrees (if possible)
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;; the range of motion or joint function is ADDITIONALLY LIMITED
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;; by pain, fatigue, weakness, or lack of endurance following
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;; repetitive use. If more than one of these is present, state,
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;; if possible, which has the major functional impact.
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;; 4. Describe objective evidence of painful motion, edema, effusion,
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;; instability, weakness, tenderness, redness, heat, abnormal
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;; movement, guarding of movement, etc.
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;; 5. For weight bearing joints (hip, knee, ankle), describe gait
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;; and functional limitations on standing and walking. Describe
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;; any callosities, breakdown, or unusual shoe wear pattern that
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;; would indicate abnormal weight bearing.
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;; 6. If ankylosis is present, describe the position of the bones of
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;; the joint in relationship to one another (in degrees of flexion,
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;; external rotation, etc.), and state whether the ankylosis is
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;; stable and pain free.
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;; 7. If indicated, measure the leg length from the anterior superior
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;; iliac spine to the medial malleolus.
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;; 8. For INFLAMMATORY ARTHRITIS, describe any constitutional signs.
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;; 9. Describe range of motion with prosthesis in same detail as
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;; described above for non-prosthetic joints.
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;;
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;;
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;;D. Normal Range of Motion: All joint Range of Motion measurements
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;;must be made using a goniometer. Show each measured range of motion
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;;separately rather than as a continuum. For example, if the veteran
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;;lacks 10 degrees of full knee extension and has normal flexion, show
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;;the range of motion as extension to minus 10 degrees (or lacks 10
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;;degrees of extension) and flexion 0 to 140 degrees.
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;;
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;; 1. Hip range of motion: (Movement of femur as it rotates in the
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;; acetabulum.)
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;;
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;; a. Normal range of motion, using the anatomical position as
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;; zero degrees.
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;;
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;; Flexion = 0 to 125 degrees (To gain a true picture of hip
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;; flexion, i.e., movement between the pelvis and femur in
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;; the hip joint, the opposite thigh should be extended to
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;; minimize motion between the pelvis and spine.)
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;;
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;; Extension = 0 to 30 degrees.
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;;
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;; Adduction = 0 to 25 degrees.
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;;
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;; Abduction = 0 to 45 degrees.
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;;
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;; External rotation = 0 to 60 degrees.
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;;
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;; Internal rotation = 0 to 40 degrees.
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;;
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;;
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;;
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;; 2. Knee range of motion:
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;;
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;; a. Normal range of motion, using the anatomical position as
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;; zero degrees.
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;;
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;; Flexion = 0 to 140 degrees.
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;;
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;; Extension - zero degrees = full extension. Show loss of
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;; extension by describing the degrees in which extension is
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;; not possible. (e.g., Show range of motion as extension to
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;; minus 10 degrees and flexion 0 to 140 degrees when full
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;; extension is limited by 10 degrees and full flexion is
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;; possible.)
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;;
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;; b. Stability.
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;;
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;; Medial and Lateral Collateral Ligaments: Varus/valgus in
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;; neutral and in 30 degrees of flexion - normal is no motion.
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;;
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;; Anterior and Posterior Cruciate Ligaments: Anterior/posterior
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;; in 30 degrees of flexion with foot stabilized - normal is
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;; less than 5 mm. of motion (1/4 inch - Lachman's test) or in
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;; 90 degrees of flexion with foot stabilized - normal is less
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;; than 5mm. of motion (1/4 inch - anterior and posterior drawer
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;; test).
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;;
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;; Medial and Lateral Meniscus: Perform McMurray's test.
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;;
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;;
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;; 3. Ankle range of motion:
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;;
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;; a. Neutral position is with foot at 90 degrees to ankle.
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;; From that position, dorsiflexion is 0 to 20 degrees;
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;; plantar flexion is 0 to 45 degrees.
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;; b. Describe any varus or valgus angulation of the os calcis
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;; in relationship to the long axis of the tibia and fibula.
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;;
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;;
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;; 4. Shoulder, elbow, forearm, and wrist range of motion:
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;;
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;; a. Normal range of motion is measured with zero degrees the
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;; anatomical position except for 2 situations:
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;;
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;; i. Supination and pronation of the forearm is measured
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;; with the arm against the body, the elbow flexed to 90
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;; degrees, and the forearm in mid position (zero degrees)
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;; between supination and pronation.
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;; ii. Shoulder rotation is measured with the arm abducted
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;; to 90 degrees, the elbow flexed to 90 degrees, and
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;; the forearm reflecting the midpoint (zero degrees)
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;; between internal and external rotation of the shoulder.
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;;
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;;
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;; b. Shoulder forward flexion = zero to 180 degrees.
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;; c. Shoulder abduction = zero to 180 degrees.
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;; d. Shoulder external rotation = zero to 90 degrees.
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;; e. Shoulder internal rotation = zero to 90 degrees.
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;; f. Elbow flexion = zero to 145 degrees.
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;; g. Forearm supination = zero to 85 degrees.
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;; h. Forearm pronation = zero to 80 degrees.
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;; i. Wrist dorsiflexion (extension) = zero to 70 degrees.
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;; j. Wrist palmar flexion = zero to 80 degrees.
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;; k. Wrist radial deviation = zero to 20 degrees.
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;; l. Wrist ulnar deviation = zero to 45 degrees.
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;;
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;;
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;;E. Diagnostic and Clinical Tests:
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;;
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;; 1. As indicated: X-rays, including special views or weight
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;; bearing films, MRI, arthrogram, diagnostic arthroscopy.
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;; NOTE: The diagnosis of degenerative arthritis or post-traumatic
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;; arthritis of a joint requires X-ray confirmation. Once the diagnosis
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;; has been confirmed in a joint, further X-rays of that joint are not
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;; required.
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;; 2. Include results of all diagnostic and clinical tests in the examination
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;; report.
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;;
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;;
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;;
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;;F. Diagnosis:
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;;
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;;
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;;Signature: Date:
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;;END
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