DVBCWGM1 ;ALB/CMM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;Narrative: This is a complete, base-line examination covering all
;;parts of the body, not just the areas claimed by the veteran. The
;;examiner may request any additional studies or examinations as needed
;;for proper diagnosis and evaluation. All important negatives should
;;be reported. If a diagnosis is uncovered that was not originally
;;claimed by the veteran, complete the appropriate worksheet, in
;;addition to this one. A general medical examination may also be
;;requested as evidence for non service-connected disability pension
;;claims or for claimed entitlement to individual unemployability
;;benefits in service-connected disability compensation claims.
;;
;;A. REVIEW OF MEDICAL RECORDS;
;;
;;
;;
;;B. MEDICAL HISTORY (Subjective Complaints):
;;
;; Comment on:
;; 1. If the injury or disease OCCURRED IN THE MILITARY:
;; a. Completely describe the circumstances, injury, treatment,
;; follow-up, and residuals in the military.
;;
;;
;; b. Completely describe the circumstances, injury, treatment,
;; follow-up, and residuals after the military.
;;
;;
;; 2. If the injury or disease OCCURRED BEFORE THE MILITARY:
;; a. Completely describe the circumstances, injury, treatment,
;; follow-up, and residuals before entering the military.
;;
;;
;; b. Completely describe any worsening of residuals due to being
;; in the military.
;;
;;
;; c. Completely describe the circumstances, injury, treatment,
;; follow-up, and residuals after the military.
;;
;;
;; 3. If the injury or disease OCCURRED AFTER THE MILITARY:
;; a. Completely describe the circumstances, injury, treatment,
;; follow-up, and residuals after the military.
;;
;;
;; 4. Occupational history:
;; a. Obtain the name and address of the employer (list most
;; current first), type of occupation, employment dates,
;; wages for last 12 months. If any time was lost from work,
;; please describe the reason and extent of time lost.
;;
;;
;;C. PHYSICAL EXAMINATION (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; The examiner should incorporate all ancillary study results into
;; the final diagnoses.
;;
;; 1. VS: Heart rate, blood pressure (If the diagnosis of hypertension
;; has not been established, take 2 or more blood pressure readings
;; on at least 3 different days. If hypertension has been
;; diagnosed, take 2 or more blood pressure readings.), respirations,
;; height, weight, maximum weight in past year, weight change in
;; past year, body build, and state of nutrition.
;;
;;
;; 2. DOMINANT HAND: Indicate the dominant hand and how determined
;; (i.e., writes, eats, combs hair, etc.).
;;
;;
;; 3. POSTURE AND GAIT: (If abnormal, describe.)
;;
;;
;; 4. SKIN, INCLUDING APPENDAGES: (If abnormal, describe appearance,
;; location, extent of lesions and limitations to daily activity.)
;; If there are laceration or burn scars, describe the location,
;; measurements (cm. x cm.), shape, depression, type of tissue
;; loss, adherence, disfigurement and tenderness. For each burn
;; scar, state if due to a 2nd or 3rd degree burn. (NOTE: If
;; the skin condition or scars are disfiguring, obtain COLOR
;; PHOTOGRAPHS of affected area(s).
;;
;;
;; 5. HEMIC AND LYMPHATIC: (Describe local or generalized adenopathy,
;; tenderness, suppuration, etc.)
;;
;;
;; 6. HEAD AND FACE: Describe scars, deformities, etc.
;;
;;
;; 7. EYES: Describe external eye, pupil reaction, movements, field
;; of vision,any uncorrectable refractive error, or any retinopathy.
;;
;;
;; 8. EARS: Describe canals, drums, perforations, discharge.
;;
;;
;; 9. NOSE, SINUSES, MOUTH AND THROAT: Include gross dental findings.
;;
;;
;; 10. NECK: Describe lymph nodes, thyroid, etc.
;;
;;
;; 11. CHEST: Inspection, palpation, percussion, auscultation. If
;; abnormal, describe limitations of daily living (i.e., How far
;; can veteran walk, how many flights of stairs can he or she
;; climb, etc.).
;;
;;
;; 12. BREAST: Comment on any masses palpated in breast parenchyma
;; including axillary tail. Comment on any skin abnormalities.
;; Comment on any discharge from nipples.
;;
;;
;; 13. CARDIOVASCULAR: Record pulse, heart sounds, abnormalities
;; (i.e., arrhythmias, murmurs, etc.), and status of peripheral
;; vessels. Note edema. Describe varicose veins including
;; location, size, extent, ulcers, scars, and competency of deep
;; circulation. Examine for evidence of residuals of frostbite
;; when indicated. See Cold Injuries Examination Worksheet.
;; (NOTE: Cardiovascular signs and symptoms should be graded
;; using NYHA scale.)
;;
;;
;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
;; If abnormal, describe (i.e., abdominal enlargement, masses,
;; tenderness, etc.).
;;
;;
;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
;; testicles, epididymis, and spermatic cord. (If hernia,
;; describe type, location, size, whether complete, reducible,
;; recurrent, supported by truss or belt, and whether or not
;; operable). Inspection of anus for fissures, hemorrhoids,
;; ulcerations, etc., and digital exam of rectal walls, and prostate.
;;
;;
;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam should include inspection
;; of introitus, vagina, and cervix, palpation of labia, vagina,
;; cervix, uterus, adnexa, and ovaries. Pap smear (if none within
;; past year). Inspection of anus for fissures, hemorrhoids,
;; ulcerations, etc., and digital exam of rectal walls. Any
;; severe abnormalities may be referred to a specialist.
;;
;;
;; 17. MUSCULOSKELETAL: For joint or muscle defects, describe
;; location, swelling, atrophy, tenderness, active and passive
;; motion in degrees using a goniometer, angle of fixation,
;; fracture, fibrous or bony residual, and mechanical aids used
;; by veteran. Provide an assessment of the effect on range of
;; motion and joint function of pain, weakness, fatigue, or
;; incoordination following repetitive use or during flare-ups.
;; (See the appropriate worksheet for more detail.) If foot
;; problems exist, perform above exam and also include objective
;; evidence of pain at rest and on manipulation, rigidity, spasm,
;; circulatory disturbance, swelling, callus, loss of strength,
;; mobility of ankles an feet, and whether acquired or congenital.
;;
;;
;; 18. ENDOCRINE: Describe disease of thyroid, pituitary, adrenals,
;; gonads, other body systems affected, etc.
;;
;;
;; 19. NEUROLOGICAL: Cerebrum - orientation and memory. Cerebellum
;; - gait, stance, coordination. Spinal Cord - deep tendon
;; reflexes, pain, touch, temperature, vibration, position.
;; Cranial nerves - I-XII. If abnormalities are found, describe
;; region of CNS affected.
;;
;;
;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
;; response, emotional reaction, signs of tension, and response
;; to social and occupational environment. State whether the
;; veteran is capable of managing his or her benefit payments in
;; his or her own best interest without restriction. (A physical
;; disability which prevents the veteran from attending to
;; financial matters in person is not a proper basis for a
;; finding of incompetency unless the veteran is, by reason of
;; that disability, incapable of directing someone else in
;; handling the individual's financial affairs.)
;;
;;
;;D. DIAGNOSTIC AND CLINICAL TESTS:
;;
;; 1. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;; 2. All test results must be reviewed prior to final summary and
;; diagnosis.
;;
;;TOF
;;E. DIAGNOSIS:
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWGM1 8916 printed Apr 09, 2024@20:57:27 Page 2
DVBCWGM1 ;ALB/CMM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
+1 ;;2.7;AMIE;**12**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;;Narrative: This is a complete, base-line examination covering all
+2 ;;parts of the body, not just the areas claimed by the veteran. The
+3 ;;examiner may request any additional studies or examinations as needed
+4 ;;for proper diagnosis and evaluation. All important negatives should
+5 ;;be reported. If a diagnosis is uncovered that was not originally
+6 ;;claimed by the veteran, complete the appropriate worksheet, in
+7 ;;addition to this one. A general medical examination may also be
+8 ;;requested as evidence for non service-connected disability pension
+9 ;;claims or for claimed entitlement to individual unemployability
+10 ;;benefits in service-connected disability compensation claims.
+11 ;;
+12 ;;A. REVIEW OF MEDICAL RECORDS;
+13 ;;
+14 ;;
+15 ;;
+16 ;;B. MEDICAL HISTORY (Subjective Complaints):
+17 ;;
+18 ;; Comment on:
+19 ;; 1. If the injury or disease OCCURRED IN THE MILITARY:
+20 ;; a. Completely describe the circumstances, injury, treatment,
+21 ;; follow-up, and residuals in the military.
+22 ;;
+23 ;;
+24 ;; b. Completely describe the circumstances, injury, treatment,
+25 ;; follow-up, and residuals after the military.
+26 ;;
+27 ;;
+28 ;; 2. If the injury or disease OCCURRED BEFORE THE MILITARY:
+29 ;; a. Completely describe the circumstances, injury, treatment,
+30 ;; follow-up, and residuals before entering the military.
+31 ;;
+32 ;;
+33 ;; b. Completely describe any worsening of residuals due to being
+34 ;; in the military.
+35 ;;
+36 ;;
+37 ;; c. Completely describe the circumstances, injury, treatment,
+38 ;; follow-up, and residuals after the military.
+39 ;;
+40 ;;
+41 ;; 3. If the injury or disease OCCURRED AFTER THE MILITARY:
+42 ;; a. Completely describe the circumstances, injury, treatment,
+43 ;; follow-up, and residuals after the military.
+44 ;;
+45 ;;
+46 ;; 4. Occupational history:
+47 ;; a. Obtain the name and address of the employer (list most
+48 ;; current first), type of occupation, employment dates,
+49 ;; wages for last 12 months. If any time was lost from work,
+50 ;; please describe the reason and extent of time lost.
+51 ;;
+52 ;;
+53 ;;C. PHYSICAL EXAMINATION (Objective Findings):
+54 ;;
+55 ;; Address each of the following and fully describe current findings:
+56 ;; The examiner should incorporate all ancillary study results into
+57 ;; the final diagnoses.
+58 ;;
+59 ;; 1. VS: Heart rate, blood pressure (If the diagnosis of hypertension
+60 ;; has not been established, take 2 or more blood pressure readings
+61 ;; on at least 3 different days. If hypertension has been
+62 ;; diagnosed, take 2 or more blood pressure readings.), respirations,
+63 ;; height, weight, maximum weight in past year, weight change in
+64 ;; past year, body build, and state of nutrition.
+65 ;;
+66 ;;
+67 ;; 2. DOMINANT HAND: Indicate the dominant hand and how determined
+68 ;; (i.e., writes, eats, combs hair, etc.).
+69 ;;
+70 ;;
+71 ;; 3. POSTURE AND GAIT: (If abnormal, describe.)
+72 ;;
+73 ;;
+74 ;; 4. SKIN, INCLUDING APPENDAGES: (If abnormal, describe appearance,
+75 ;; location, extent of lesions and limitations to daily activity.)
+76 ;; If there are laceration or burn scars, describe the location,
+77 ;; measurements (cm. x cm.), shape, depression, type of tissue
+78 ;; loss, adherence, disfigurement and tenderness. For each burn
+79 ;; scar, state if due to a 2nd or 3rd degree burn. (NOTE: If
+80 ;; the skin condition or scars are disfiguring, obtain COLOR
+81 ;; PHOTOGRAPHS of affected area(s).
+82 ;;
+83 ;;
+84 ;; 5. HEMIC AND LYMPHATIC: (Describe local or generalized adenopathy,
+85 ;; tenderness, suppuration, etc.)
+86 ;;
+87 ;;
+88 ;; 6. HEAD AND FACE: Describe scars, deformities, etc.
+89 ;;
+90 ;;
+91 ;; 7. EYES: Describe external eye, pupil reaction, movements, field
+92 ;; of vision,any uncorrectable refractive error, or any retinopathy.
+93 ;;
+94 ;;
+95 ;; 8. EARS: Describe canals, drums, perforations, discharge.
+96 ;;
+97 ;;
+98 ;; 9. NOSE, SINUSES, MOUTH AND THROAT: Include gross dental findings.
+99 ;;
+100 ;;
+101 ;; 10. NECK: Describe lymph nodes, thyroid, etc.
+102 ;;
+103 ;;
+104 ;; 11. CHEST: Inspection, palpation, percussion, auscultation. If
+105 ;; abnormal, describe limitations of daily living (i.e., How far
+106 ;; can veteran walk, how many flights of stairs can he or she
+107 ;; climb, etc.).
+108 ;;
+109 ;;
+110 ;; 12. BREAST: Comment on any masses palpated in breast parenchyma
+111 ;; including axillary tail. Comment on any skin abnormalities.
+112 ;; Comment on any discharge from nipples.
+113 ;;
+114 ;;
+115 ;; 13. CARDIOVASCULAR: Record pulse, heart sounds, abnormalities
+116 ;; (i.e., arrhythmias, murmurs, etc.), and status of peripheral
+117 ;; vessels. Note edema. Describe varicose veins including
+118 ;; location, size, extent, ulcers, scars, and competency of deep
+119 ;; circulation. Examine for evidence of residuals of frostbite
+120 ;; when indicated. See Cold Injuries Examination Worksheet.
+121 ;; (NOTE: Cardiovascular signs and symptoms should be graded
+122 ;; using NYHA scale.)
+123 ;;
+124 ;;
+125 ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
+126 ;; If abnormal, describe (i.e., abdominal enlargement, masses,
+127 ;; tenderness, etc.).
+128 ;;
+129 ;;
+130 ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
+131 ;; testicles, epididymis, and spermatic cord. (If hernia,
+132 ;; describe type, location, size, whether complete, reducible,
+133 ;; recurrent, supported by truss or belt, and whether or not
+134 ;; operable). Inspection of anus for fissures, hemorrhoids,
+135 ;; ulcerations, etc., and digital exam of rectal walls, and prostate.
+136 ;;
+137 ;;
+138 ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam should include inspection
+139 ;; of introitus, vagina, and cervix, palpation of labia, vagina,
+140 ;; cervix, uterus, adnexa, and ovaries. Pap smear (if none within
+141 ;; past year). Inspection of anus for fissures, hemorrhoids,
+142 ;; ulcerations, etc., and digital exam of rectal walls. Any
+143 ;; severe abnormalities may be referred to a specialist.
+144 ;;
+145 ;;
+146 ;; 17. MUSCULOSKELETAL: For joint or muscle defects, describe
+147 ;; location, swelling, atrophy, tenderness, active and passive
+148 ;; motion in degrees using a goniometer, angle of fixation,
+149 ;; fracture, fibrous or bony residual, and mechanical aids used
+150 ;; by veteran. Provide an assessment of the effect on range of
+151 ;; motion and joint function of pain, weakness, fatigue, or
+152 ;; incoordination following repetitive use or during flare-ups.
+153 ;; (See the appropriate worksheet for more detail.) If foot
+154 ;; problems exist, perform above exam and also include objective
+155 ;; evidence of pain at rest and on manipulation, rigidity, spasm,
+156 ;; circulatory disturbance, swelling, callus, loss of strength,
+157 ;; mobility of ankles an feet, and whether acquired or congenital.
+158 ;;
+159 ;;
+160 ;; 18. ENDOCRINE: Describe disease of thyroid, pituitary, adrenals,
+161 ;; gonads, other body systems affected, etc.
+162 ;;
+163 ;;
+164 ;; 19. NEUROLOGICAL: Cerebrum - orientation and memory. Cerebellum
+165 ;; - gait, stance, coordination. Spinal Cord - deep tendon
+166 ;; reflexes, pain, touch, temperature, vibration, position.
+167 ;; Cranial nerves - I-XII. If abnormalities are found, describe
+168 ;; region of CNS affected.
+169 ;;
+170 ;;
+171 ;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
+172 ;; response, emotional reaction, signs of tension, and response
+173 ;; to social and occupational environment. State whether the
+174 ;; veteran is capable of managing his or her benefit payments in
+175 ;; his or her own best interest without restriction. (A physical
+176 ;; disability which prevents the veteran from attending to
+177 ;; financial matters in person is not a proper basis for a
+178 ;; finding of incompetency unless the veteran is, by reason of
+179 ;; that disability, incapable of directing someone else in
+180 ;; handling the individual's financial affairs.)
+181 ;;
+182 ;;
+183 ;;D. DIAGNOSTIC AND CLINICAL TESTS:
+184 ;;
+185 ;; 1. Include results of all diagnostic and clinical tests conducted
+186 ;; in the examination report.
+187 ;; 2. All test results must be reviewed prior to final summary and
+188 ;; diagnosis.
+189 ;;
+190 ;;TOF
+191 ;;E. DIAGNOSIS:
+192 ;;
+193 ;;
+194 ;;
+195 ;;Signature: Date:
+196 ;;END
