VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWHT2.m

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DVBCWHT2 ;ALB/JER HAND, THUMB, FINGERS WKS TEXT ; 31 JULY 2003
;;2.7;AMIE;**58**;JULY 31, 2003
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;;Are there flair ups of joint disease affecting hand, thumb or fingers?
;; If so:
;; 1. State severity, frequency and duration of flair ups.
;; 2. Name precipitating and alleviating factors.
;; 3. Estimate to what extent, if any, flair ups result in additional
;; limitation of motion or functional impairment.
;;
;;C. Physical Examination (Objective Findings):
;;Designate fingers as: thumb, index, long, ring, and little. Provide a detailed
;;assessment of each affected joint. State whether the individual is right
;;or left hand dominant. Use a goniometer for measuring joint angles. Refer to
;;Residuals of Amputations worksheet, if applicable.
;;
;; 1. Evaluation of Ankylosis
;;For each anklyosed joint, include angle of anklyosis. Describe any rotation or
;;any angulation of bone.
;;Zero degrees of flexion represents the fingers fully extended, making a
;;straight line with the rest of the hand.
;; The "position of function" of the hand is:
;; Wrist dorsiflexion: 20 to 30 degrees
;; Metacarpophalangeal flexion: 30 degrees
;; Proximal interphalangeal joint flexion: 30 degrees
;; Thumb abduction and rotation: thumb pad faces the finger pads.
;;
;; 2. Evaluation of Limitation of Motion of Single or Multiple Digits of the
;; Hand
;;Provide range of motion for each digit of the hand.
;;Normal Ranges of Motion for wrist, index, long, ring and little fingers:
;; Metacarpophalangeal joint (wrist): zero to 90 degrees of flexion
;; Proximal interphalangeal joint: zero to 100 degrees of flexion
;; Distal (terminal) interphalangeal joint: zero to 70 or 80 degrees of flexion
;;
;; 3. Evaluation of Hand as a unit
;;Measure the gap, in inches:
;; Between the tip of the thumb and the fingers
;; Between the tips of the fingers and the proximal transverse crease of the palm
;; Between the thumb pad and the fingers with the thumb attempting to oppose
;; the fingers
;; Describe strength for pushing, pulling and twisting. Describe dexterity for
;; twisting, probing, writing, touching and expression. Comment on whether and
;; how (e.g. decreased range of motion, in degrees) the flexion deformity
;; interferes with the function of the other fingers.
;;
;; 4. Additional detailed measurements and consideration of other factors
;; affecting function
;;Measure the active and passive range of motion of each affected joint. Include
;;movement against gravity and against strong resistance.
;;State whether and to what extent the range of motion (in degrees) or joint
;;function is additionally limited by pain, fatigue, weakness, or lack of
;;endurance following repetitive use or during flair-ups. If more than one
;;of these is present, state, if possible, which has the major functional
;;impact. Include rationale for conclusions.
;;
;; D. Diagnostic and Clinical Tests:
;;Include results of all diagnostic and clinical tests upon which examiner is
;;basing the diagnosis.
;;
;; E. Diagnosis:
;;
;;
;;
;;
;;Signature: Date:
;;END