Bones (Fractures and Bone Disease)

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Describe details of any injury.
2. For episodes of osteomyelitis, location, frequency. Is there current active infection? If not, when was the last active infection?
3. History of hospitalizations or surgery, reason or type of surgery, location and dates, if known.
4. Symptoms of pain, weakness, stiffness, swelling, heat, redness, drainage, instability or giving way, "locking," abnormal motion, etc.
5. Hand dominance and how determined.
6. Treatment: medication type, dose, frequency, response, and side effects; other treatment.
7. If there are periods of flare-up of bone disease:

1. State their severity, frequency, and duration.
2. Name the precipitating and alleviating factors.
3. Estimate to what extent, if any, per veteran, they affect functional impairment during the flare-up.

8. Describe whether crutches, brace, cane, corrective shoes, etc., are needed.
9. Are there constitutional symptoms of bone disease?
10. Describe the effects of the condition on the veteran's usual occupation and daily activities.
11. History of neoplasm.

1. Date of diagnosis, diagnosis.
2. Benign or malignant.
3. Type of treatment, dates.
4. Last date of treatment.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the disability being examined and fully describe current findings:

1. Describe objective evidence of deformity, angulation, false motion, shortening, intra- articular involvement, etc.
2. Malunion, nonunion, any loose motion, false joint.
3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.
4. For weight bearing joints (hip, knee, ankle), describe gait and functional limitations on standing and walking. Describe any callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight bearing.
5. If ankylosis is present, describe the position of the bones of the joint in relationship to one another (in degrees of flexion, external rotation, etc.), and state whether the ankylosis is stable and pain free.
6. With joint involvement, a detailed assessment of each affected joint is required. Follow JOINTS worksheet.
7. If shortening of the leg may be present, measure the leg length from the anterior superior iliac spine to the medial malleolus.
8. Are there constitutional signs of bone disease - anemia, weight loss, fever, debility, amyloid liver, etc.?
9. For genu recurvatum, acquired, traumatic; Is there weakness and insecurity on weight-bearing?
10. For malunion of os calcis or astralgus - degree of deformity (mild, moderate, marked).

D. Diagnostic and Clinical Tests:

1. As indicated: X-rays, including special views or weight bearing films, MRI, arthrogram, diagnostic arthroscopy. Note: The diagnosis of degenerative arthritis or post-traumatic arthritis of a joint requires X-ray confirmation. Once the diagnosis has been confirmed in a joint, further X-rays of that joint are not required.
2. For osteomyelitis, state whether there is an involucrum, sequestrum, or draining sinus.
3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: