VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWAR1.m

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DVBCWAR1 ;ALB/CMM AMPUTATION, RESIDUALS OF WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. The location of the amputation site.
;;
;;
;; 2. If symptoms exist, describe precipitating factors, aggravating
;; factors, alleviating factors, alleviating medications, frequency,
;; severity, and duration.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Swelling, deformity, tenderness of stump.
;;
;;
;; 2. Skin, including scar.
;;
;;
;; 3. Circulation.
;;
;;
;;
;; 4. Muscles.
;;
;;
;;
;; 5. Describe any limited motion or instability in the joint above
;; the amputation site.
;;
;;
;; 6. A DETAILED ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED.
;;
;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
;; of motion, including movement against gravity and against
;; strong resistance.
;;
;;
;; b. If the joint is painful on motion, state at what point in
;; the range of motion pain begins and ends.
;;
;;
;; c. State to what extent, if any, the range of motion or function
;; is ADDITIONALLY limited by pain, fatigue, weakness, or lack
;; of endurance. If more than one of these is present, state,
;; if possible, which has the major functional impact.
;;
;;
;; 7. Bones.
;;
;;
;; 8. Length of stump.
;;
;;
;; 9. Neuroma, if present.
;;
;;
;; 10. Is amputation of lower extremity improbable by prosthesis
;; controlled by natural knee action?
;;
;;
;;MEASUREMENT OF THE STUMP:
;;
;;The stump of an amputated THIGH will be measured from the perineum, at
;;the origin of the adductor tendons, to the bony end of the stump, with
;;the claimant recumbent and the stump lying parallel with the other lower
;;limb. It is to be kept in mind that if the limb is abducted, flexed,
;;rotated or adducted, its length will be altered. The effective length
;;of a thigh stump is governed by its inside dimension. Measure length
;;of normal thigh if present and indicate whether amputation is in upper,
;;middle, or lower third. When amputation is bilateral, estimate the same
;;for a person of similar height.
;;
;;The stump of an amputated LEG BELOW THE KNEE must be measured from the
;;insertion of the internal hamstring muscles to the bony end of the stump
;;with the patient recumbent and the leg flexed at 90 degrees.
;;
;;The stump of an amputated ARM should be measured from the anterior
;;axillary fold to the bony end of the stump, with the stump hanging
;;parallel to the chest wall. Indicate whether the amputation site is
;;above or below the insertion of the deltoid muscle. A statement of
;;the remaining function is the best indicator of a disability's severity.
;;
;;The stump of an amputated FOREARM should be measured from the insertion
;;of the biceps tendon to the bony end, with the elbow flexed at 90
;;degrees. Indicate if the amputation site is above or below the
;;attachment of the pronator teres.
;;
;;TOF
;;Amputations of FINGERS should be described as through the distal,
;;middle, or proximal phalanx or as disarticulations through the
;;distal interphalangeal, proximal interphalangeal, or
;;metacarpophalangeal joint. Resection of the head of the metacarpal
;;will always be reported if shown. Complete or partial loss or resection
;;of bones of the hand will described in terms of the fraction of each
;;remaining. If surgery has altered the usefulness of remaining or
;;transplanted digits, this will be described.
;;
;;Complete or partial loss of TOES or METATARSAL OR TARSAL BONES should
;;be described as in the subparagraph above. Always report loss of
;;metatarsal head or other defects. Indicate if amputation is through
;;the tarsal-metatarsal joint and if any other portions of the bones of
;;the foot remain.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. X-ray if exact amputation level is not of record.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; Amputations must be described in accordance with the following levels:
;; 1. ARM:
;; a. Disarticulation.
;; b. Amputation above insertion of deltoid muscle.
;; c. Amputation below insertion of deltoid muscle.
;;
;;
;; 2. FOREARM:
;; a. Above radial insertion of pronator teres (function is best
;; indicator of disability).
;; b. Below insertion of pronator teres.
;;
;;
;; 3. THIGH:
;; a. Disarticulation, with loss of extrinsic pelvic girdle muscles.
;; b. Amputation of upper, middle or lower third, always measured
;; from perineum to the bony end of the stump with the
;; claimant recumbent and stump lying parallel with the other
;; lower limb.
;; c. State whether this level permits satisfactory prosthesis.
;;
;;
;;TOF
;; 4. LEG:
;; a. Give level of amputation and condition of stump.
;; b. State whether this level permits a satisfactory prosthesis.
;; c. Describe any stump defects (e.g., painful neuroma or
;; circulatory disturbance).
;;
;;
;;Signature: Date:
;;END