132 lines
4.3 KiB
Mathematica
132 lines
4.3 KiB
Mathematica
DVBCWB1 ;ALB/CMM BONES WKS TEXT - 1 ; 6 MARCH 1997
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;;2.7;AMIE;**12**;Apr 10, 1995
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;
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;
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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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;; 1. Describe details of any injury, episodes of osteomyelitis, or
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;; surgery.
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;;
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;;
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;; 2. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
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;; drainage, instability or giving way, "locking," abnormal motion, etc.
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;;
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;;
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;; 3. Treatment: medication type, dose, frequency, response, and
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;; side effects; other treatment.
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;;
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;;
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;; 4. If there are periods of flare-up of bone disease:
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;; a. State their severity, frequency, and duration.
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;;
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;;
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;; b. Name the precipitating and alleviating factors.
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;;
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;;
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;; c. Estimate to what extent, if any, they affect functional
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;; impairment during the flare-up.
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;;
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;;
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;;
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;; 5. Is there current active infection? If not, when was the last
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;; active infection? How was it determined?
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;;
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;;
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;; 6. Describe whether crutches, brace, cane, corrective shoes, etc.,
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;; are needed.
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;;
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;;
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;; 7. Are there constitutional symptoms of bone disease?
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;;
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;;
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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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;;
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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 disability
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;; being examined and fully describe current findings:
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;;
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;; 1. Describe objective evidence of deformity, angulation, false
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;; motion, shortening, intra-articular involvement, etc.
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;;
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;;
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;; 2. Malunion, nonunion, any loose motion, false joint.
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;;
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;;
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;; 3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
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;;
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;;
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;; 4. 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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;;
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;;
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;; 5. If ankylosis is present, describe the position of the bones
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;; of the joint in relationship to one another (in degrees of
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;; flexion, external rotation, etc.), and state whether the
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;; ankylosis is stable and pain free.
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;;
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;;
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;; 6. With joint involvement, A DETAILED ASSESSMENT OF EACH AFFECTED
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;; JOINT IS REQUIRED.
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;; NOTE: See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and
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;; Ankle for normal range of motion of those joints.
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;;
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;;
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;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
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;; of motion, including movement against gravity and against
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;; strong resistance.
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;;
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;;
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;; b. If the joint is painful on motion, state at what point in
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;; the range of motion pain begins and ends.
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;;
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;;
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;; c. State to what extent, if any, the range of motion or
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;; function is ADDITIONALLY limited by pain, fatigue,
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;; weakness, or lack of endurance. If more than one of
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;; these is present, state, if possible, which has the major
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;; functional impact.
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;;
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;;
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;; 7. If shortening of the leg may be present, measure the leg
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;; length from the anterior superior iliac spine to the medial
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;; malleolus.
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;;
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;;
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;; 8. Are there constitutional signs of bone disease - anemia,
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;; weight loss, fever, debility, amyloid liver, etc.?
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;;
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;;
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;;
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;;D. 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
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;; diagnosis has been confirmed in a joint, further X-rays of that
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;; joint are not required.
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;; 2. For osteomyelitis, state whether there is an involucrum,
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;; sequestrum, or draining sinus.
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;; 3. Include results of all diagnostic and clinical tests
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;; conducted in the examination report.
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;;
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;;
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;;
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;;E. Diagnosis:
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;;
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;;
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;;
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;;Signature: Date:
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;;END
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