VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWSW3.m

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DVBCWSW3 ;ALB/CMM SCARS WKS TEXT - 1 ; 11/20/02 3:04pm
;;2.7;AMIE;**49**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; 1. Type of injury or infection causing the wound or scar, its
;; date, the treatment used, and the response to such treatment.
;;
;;
;; 2. Current symptoms.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; For every scar to be examined, address EACH of the following and
;; fully describe the current findings. Note that, in addition
;; to measuring the scar itself, measurements of areas with certain
;; abnormal characteristics must also be provided. All measurements
;; should be reported in inches or centimeters.
;; 1. Describe precise location of each scar. Draw diagram if
;; necessary.
;;
;;
;; 2. Give MEASUREMENT of length and width (at its widest part) of
;; each scar.
;;
;;
;; 3. Is there pain in the scar on examination?
;;
;;
;; 4. Is there adherence to underlying tissue?
;;
;;
;; 5. Texture of skin. If irregular, atrophic, shiny, scaly, etc.,
;; give MEASUREMENT of length and width of area so affected.
;;
;;
;; 6. Is the scar unstable, meaning is there frequent loss of
;; covering of skin over the scar, such as from ulceration or
;; breakdown of skin?
;;
;;
;; 7. Is there elevation or depression of the surface contour
;; of the scar on palpation?
;;
;;
;; 8. Is the scar superficial (meaning there is no underlying
;; soft tissue damage)?
;;
;;
;; 9. Is the scar deep (meaning there is underlying soft tissue
;; loss or damage)? If yes, give MEASUREMENT of length and
;; width of underlying soft tissue damage.
;;
;;
;; 10. Describe any inflammation, edema, or keloid formation.
;;
;;
;; 11. Describe color of scar compared to normal areas of skin
;; (give MEASUREMENT of length and width of any hypopigmentation
;; or hyperpigmentation).
;;
;;
;; 12. For face, discuss whether there is gross distortion or
;; asymmetry of any feature or set of paired features (nose,
;; chin, forehead, eyes (including eyelids), ears (auricles),
;; cheeks, lips).
;;
;;
;; 13. Is there an area of induration and inflexibility of skin in
;; the area of the scar? If so, give MEASUREMENT of length
;; and width of area of induration.
;;
;;
;; 14. Describe any limitation of motion or other limitation of
;; function caused by a scar.
;;
;;
;; 15. With disfigurement or disfiguring scar of head, face, or
;; neck, submit COLOR PHOTOGRAPHS.
;;
;;D. Diagnostic and Clinical Tests:
;;
;; Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END