125 lines
6.3 KiB
Mathematica
125 lines
6.3 KiB
Mathematica
DVBCWNS3 ;BPOIFO/ESW - SPINE WKS TEXT - 1 ; 10/8/02 10:52am
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;;2.7;AMIE;**46**;Apr 10, 1995
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;Per VHA Directive 10-92-142, this routine should not be modified
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;
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TXT ;
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;;
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;;A. Review of Medical Records: Report whether done or not.
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;;
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;;
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;;B. Present Medical History (Subjective Complaints):
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;;
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;; 1. Report complaints of pain (including any radiation), stiffness,
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;; weakness, etc.
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;; a. Onset
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;; b. Location and distribution
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;; c. Duration
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;; d. Characteristics, quality, description
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;; e. Intensity
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;; 2. Describe treatment - type, dose, frequency, response, side effects.
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;; 3. If there are periods of flare-up:
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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. Describe any additional limitation of motion or functional
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;; impairment during the flare-up.
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;; 4. Describe associated features or symptoms (e.g., weight loss, fevers,
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;; malaise, dizziness, visual disturbances, numbness, weakness, bladder
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;; complaints, bowel complaints, erectile dysfunction).
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;; 5. Describe walking and assistive devices.
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;; a. Walk unaided? Use of a cane, crutches, walker?
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;; b. Use of orthosis (brace)?
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;; c. How far and how long can the veteran walk?
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;; d. Unsteadiness? Falls?
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;; 6. Describe details of any trauma or injury, including dates,
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;; and direction and magnitude of forces.
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;; 7. Describe details of any surgery, including dates.
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;; 8. Functional Assessment - Describe effects of the condition(s) on
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;; the veteran's mobility (e.g., walking, transfers, bed activities),
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;; activities of daily living (i.e., eating, grooming, bathing,
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;; toileting, dressing), usual occupation, recreational activities,
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;; driving.
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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 being examined and
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;;fully describe current findings:
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;; 1. Inspection: spine, limbs, posture and gait, position of the head,
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;; curvatures of the spine, symmetry in appearance, symmetry and rhythm of
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;; spinal motion.
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;; 2. Range of motion
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;; a. Using a goniometer, measure the range of motion, and show
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;; each measured range of motion (flexion, extension, etc.)
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;; separately rather than as a continuum. Measure active range of
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;; motion, and passive range of motion if active range of motion
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;; is not normal.
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;; b. State the normal range of motion when providing spine range
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;; of motion. For example, state forward flexion of the lumbar spine
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;; is 80 out of 90 degrees, and backward extension is 20 out of 35
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;; degrees. (See Chapter 11 of Clinician's Guide for more detailed
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;; discussion of spine range of motion.)
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;; c. If the range of motion is affected by factors other than
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;; spinal injury or disease, such as the claimant's body habitus,
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;; provide an estimated normal range of motion for that particular
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;; individual.
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;; d. If the spine 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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;; e. State to what extent (if any), expressed in degrees if
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;; possible, the range of motion is a d d i t i o n a l l y
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;; l i m i t e d by pain, fatigue, weakness, or lack of endurance
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;; following repetitive use or during flare-ups.
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;; If more than one of these
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;; If more than one of these is present, state, if possible, which
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;; has the major functional impact.
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;; 3. Describe objective evidence of painful motion, spasm, weakness,
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;; tenderness, etc.
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;; 4. Describe any postural abnormalities, fixed deformity (ankylosis), or
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;; abnormality of musculature of back.
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;; 5. Neurological examination
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;; a. Sensory examination, to include sacral segments.
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;; b. Motor examination (atrophy, circumferential measurements, tone,
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;; and strength).
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;; c. Reflexes (deep tendon, cutaneous, and pathologic).
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;; d. Rectal examination (sensation, tone, volitional control,
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;; and reflexes).
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;; e. Lasegue's sign.
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;; f. If the neurologic effects are not encompassed by this part
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;; of the examination (e.g., if there are bladder problems),
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;; follow appropriate worksheet for the body system affected.
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;; 6. For vertebral fractures, report the percentage of loss of height, if any,
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;; of the vertebral body.
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;; 7. Non-organic physical signs (e.g., Waddell tests, others).
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;;
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;;D. For intervertebral disc syndrome
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;;
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;; 1. Conduct and report a separate history and physical examination for
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;; each segment of the spine (cervical, thoracic, lumbar) affected by
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;; disc disease.
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;; 2. Conduct a complete history and physical examination of each affected
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;; spinal segment, whether or not there has been surgery, as described
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;; above under B and C.
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;; 3. Conduct a thorough neurologic history and examination, as described
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;; in C5, of all areas innervated by each affected spinal segment.
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;; Specify the peripheral nerve(s) affected. Include an evaluation of
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;; effects, if any, on bowel or bladder functioning.
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;; 4. Describe as precisely as possible, in number of days, the duration
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;; of each incapacitating episode during the past 12-month period.
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;; An incapacitating episode, for disability evaluation purposes,
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;; is a period of acute signs and symptoms due to intervertebral disk
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;; syndrome that requires bed rest prescribed by a physician and
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;; treatment by a physician.
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;;
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;;E. Diagnostic and Clinical Tests:
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;;
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;; 1. Imaging studies, when indicated.
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;; 2. Electrodiagnostic tests, when indicated.
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;; 3. Clinical laboratory tests, when indicated.
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;; 4. Isotope scans, when indicated.
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;; 5. Include results of all diagnostic and clinical tests conducted
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;; in the examination report.
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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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