- DVBCWGX1 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
- ;;2.7;AMIE;**26**;Apr 10, 1995
- ;
- ;
- TXT ;
- ;;NARRATIVE: This is a comprehensive base-line or screening examination for
- ;;all body systems, not just specific conditions claimed by the veteran.
- ;;It is often the initial post-discharge examination of a veteran requested
- ;;by the Compensation and Pension Service for disability compensation
- ;;purposes. As a screening examination, it is not meant to elicit the
- ;;detailed information about specific conditions that is necessary for rating
- ;;purposes. Therefore, all claimed conditions, and any found or suspected
- ;;conditions that were not claimed, should be addressed by referring to
- ;;and following all appropriate worksheets, in addition to this one, to
- ;;assure that the examination for each condition provides information
- ;;adequate for rating purposes. This does not require that a medical
- ;;specialist conduct examinations based on other worksheets, except in the
- ;;case of vision and hearing problems, mental disorders, or especially
- ;;complex or unusual problems. VISION, HEARING, AND MENTAL DISORDER
- ;;EXAMINATIONS MUST BE CONDUCTED BY A SPECIALIST. The examiner may request
- ;;any additional studies or examinations needed for proper diagnosis and
- ;;evaluation (see other worksheets for guidance). All important negatives
- ;;should be reported. The regional office may also request a general medical
- ;;examination as evidence for nonservice-connected disability pension claims
- ;;or for claimed entitlement to individual unemployability benefits in
- ;;service-connected disability compensation claims. Barring unusual
- ;;problems, examinations for pension should generally be adequate if only
- ;;this general worksheet is followed.
- ;;
- ;;
- ;;A. REVIEW OF MEDICAL RECORDS: Indicate whether the C-file was reviewed.
- ;;
- ;;
- ;;
- ;;B. MEDICAL HISTORY (Subjective Complaints):
- ;;
- ;; 1. Discuss: Whether an injury or disease that is found OCCURRED
- ;; DURING ACTIVE SERVICE, BEFORE ACTIVE SERVICE, OR AFTER ACTIVE
- ;; SERVICE. To the extent possible, describe the circumstances,
- ;; dates, specific injury or disease that occurred, treatment,
- ;; follow-up, and residuals. If the injury or disease occurred
- ;; BEFORE ACTIVE SERVICE, describe any worsening of residuals due
- ;; to being in military service. Describe current symptoms and
- ;; treatment.
- ;;
- ;;
- ;; 2. Occupational history (for PENSION and INDIVIDUAL UMEMPLOYABILITY
- ;; claims): Obtain the name and address of employers (list most
- ;; current first), type of occupation, employment dates, and wages
- ;; for last 12 months. If any time was lost from work in the past
- ;; 12-month period, please describe the reason and the extent of
- ;; time lost.
- ;;
- ;;
- ;; 3. Describe details of current treatment, conditions being treated,
- ;; and side effects of treatment.
- ;;
- ;;
- ;; 4. Describe all surgery and hospitalizations in and after service
- ;; with approximate dates.
- ;;
- ;;
- ;; 5. If a malignant neoplasm is or was present, provide:
- ;; a. Date of confirmed diagnosis.
- ;;
- ;;
- ;; b. Date of the last surgical, X-ray, antineoplastic chemotherapy,
- ;; radiation, or other therapeutic procedure.
- ;;
- ;;
- ;; c. State expected date treatment regimen is to be completed.
- ;;
- ;;
- ;; d. If treatment is already completed, provide date of last treatment.
- ;;
- ;;
- ;; e. If treatment is already completed, fully describe residuals.
- ;;
- ;;
- ;;
- ;;C. PHYSICAL EXAMINATION (Objective Findings):
- ;;
- ;; Address each of the following and fully describe current findings:
- ;; The examiner should incorporate results of all ancillary studies
- ;; into the final diagnoses.
- ;;
- ;; 1. VS: Heart rate, blood pressure (see #13 below), 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 this was
- ;; determined, e.g., writes, eats, combs hair with that hand.
- ;;
- ;;
- ;; 3. POSTURE AND GAIT: Describe abnormality and reason for it.
- ;; Describe any ambulatory aids.
- ;;
- ;;
- ;; 4. SKIN, INCLUDING APPENDAGES: If abnormal, describe appearance,
- ;; location, extent of lesions. If there are laceration or burn
- ;; scars, describe the location, exact measurements (cm. x cm.),
- ;; shape, depression, type of tissue loss, adherence, and tenderness.
- ;; For each burn scar, state if due to a 2nd or 3rd degree burn.
- ;; Describe any limitation of activity or limitation of motion
- ;; due to scarring or other skin lesions.
- ;; NOTE: If there are disfiguring scars (of face, head, or neck),
- ;; obtain COLOR PHOTOGRAPHS of the affected area(s) to submit
- ;; with the examination report.
- ;;
- ;;
- ;; 5. HEMIC AND LYMPHATIC: Describe adenopathy, tenderness,
- ;; suppuration, edema, pallor, etc.
- ;;
- ;;
- ;; 6. HEAD AND FACE: Describe scars, skin lesions, deformities, etc.,
- ;; as discussed under item #4.
- ;;
- ;;
- ;; 7. EYES: Describe external eye, pupil reaction, eye movements.
- ;;
- ;;
- ;; 8. EARS: Describe canals, drums, perforations, discharge.
- ;;
- ;;
- ;; 9. NOSE, SINUSES, MOUTH AND THROAT: Include gross dental findings.
- ;; For sinusitis, describe headaches, pain, episodes of
- ;; incapacitation, frequency and duration of antibiotic treatment.
- ;;
- ;;
- ;; 10. NECK: Describe lymph nodes, thyroid, etc.
- ;;
- ;;
- ;; 11. CHEST: Inspection, palpation, percussion, auscultation. Describe
- ;; respiratory symptoms and effect on daily activities, e.g., how
- ;; far the veteran can walk, how many flights of stairs veteran
- ;; can climb. If a respiratory condition is claimed or suspected,
- ;; refer to appropriate worksheet(s). Most respiratory conditions
- ;; will require PFT's, including post-bronchodilation studies.
- ;; Describe in detail any treatment for pulmonary disease.
- ;;
- ;;
- ;; 12. BREAST: Describe masses, scars, nipple discharge, skin
- ;; abnormalities. Give date of last mammogram, if any. Describe
- ;; any breast surgery (with approximate date) and residuals.
- ;;
- ;;
- ;; 13. CARDIOVASCULAR: NOTE: If there is evidence of a cardiovascular
- ;; disease, or one is claimed, refer to appropriate worksheet(s).
- ;;
- ;; a. Record pulse, quality of heart sounds, abnormal heart sounds,
- ;; arrhythmias. Describe symptoms and treatment for any
- ;; cardiovascular conditions, including peripheral arterial
- ;; and venous disease. Give NYHA classification of heart disease.
- ;; A determination of METS by exercise testing may be required
- ;; for certain cardiovascular conditions, and an estimation of
- ;; METS may be required if exercise testing cannot be conducted
- ;; for medical reasons. (See the cardiovascular worksheet
- ;; for further guidance.)
- ;;
- ;;
- ;; b. Describe the status of peripheral vessels and pulses.
- ;; Describe edema, stasis pigmentation or eczema, ulcers, or
- ;; other skin or nail abnormalities. Describe varicose veins,
- ;; including extent to which any resulting edema is relieved
- ;; by elevation of extremity. Examine for evidence of residuals
- ;; of cold injury when indicated. See and follow special cold
- ;; injury examination worksheet if there is a history of cold
- ;; exposure in service and the special cold injury examination
- ;; has not been previously done.
- ;;
- ;;
- ;; c. BLOOD PRESSURE: (Per the rating schedule, hypertension means
- ;; that the diastolic blood pressure is predominantly 90 mm.
- ;; or greater, and isolated systolic hypertension means that
- ;; the systolic blood pressure is predominantly 160 mm. or
- ;; greater with a diastolic blood pressure of less than 90 mm.)
- ;;
- ;; 1) If the diagnosis of hypertension has not been previously
- ;; established, and it is a claimed issue, B.P. readings
- ;; MUST be taken two or more times on each of at least
- ;; three different days.
- ;;
- ;;
- ;; 2) If hypertension has been previously diagnosed and is
- ;; claimed, but the claimant is not on treatment, B.P.
- ;; readings MUST be taken two or more times on each of
- ;; at least three different days.
- ;;
- ;;
- ;; 3) If hypertension has been previously diagnosed, and the
- ;; claimant is on treatment, take three blood pressure
- ;; readings on the day of the examination.
- ;;TOF
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWGX1 9224 printed Feb 18, 2025@23:17:54 Page 2
- DVBCWGX1 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
- +1 ;;2.7;AMIE;**26**;Apr 10, 1995
- +2 ;
- +3 ;
- TXT ;
- +1 ;;NARRATIVE: This is a comprehensive base-line or screening examination for
- +2 ;;all body systems, not just specific conditions claimed by the veteran.
- +3 ;;It is often the initial post-discharge examination of a veteran requested
- +4 ;;by the Compensation and Pension Service for disability compensation
- +5 ;;purposes. As a screening examination, it is not meant to elicit the
- +6 ;;detailed information about specific conditions that is necessary for rating
- +7 ;;purposes. Therefore, all claimed conditions, and any found or suspected
- +8 ;;conditions that were not claimed, should be addressed by referring to
- +9 ;;and following all appropriate worksheets, in addition to this one, to
- +10 ;;assure that the examination for each condition provides information
- +11 ;;adequate for rating purposes. This does not require that a medical
- +12 ;;specialist conduct examinations based on other worksheets, except in the
- +13 ;;case of vision and hearing problems, mental disorders, or especially
- +14 ;;complex or unusual problems. VISION, HEARING, AND MENTAL DISORDER
- +15 ;;EXAMINATIONS MUST BE CONDUCTED BY A SPECIALIST. The examiner may request
- +16 ;;any additional studies or examinations needed for proper diagnosis and
- +17 ;;evaluation (see other worksheets for guidance). All important negatives
- +18 ;;should be reported. The regional office may also request a general medical
- +19 ;;examination as evidence for nonservice-connected disability pension claims
- +20 ;;or for claimed entitlement to individual unemployability benefits in
- +21 ;;service-connected disability compensation claims. Barring unusual
- +22 ;;problems, examinations for pension should generally be adequate if only
- +23 ;;this general worksheet is followed.
- +24 ;;
- +25 ;;
- +26 ;;A. REVIEW OF MEDICAL RECORDS: Indicate whether the C-file was reviewed.
- +27 ;;
- +28 ;;
- +29 ;;
- +30 ;;B. MEDICAL HISTORY (Subjective Complaints):
- +31 ;;
- +32 ;; 1. Discuss: Whether an injury or disease that is found OCCURRED
- +33 ;; DURING ACTIVE SERVICE, BEFORE ACTIVE SERVICE, OR AFTER ACTIVE
- +34 ;; SERVICE. To the extent possible, describe the circumstances,
- +35 ;; dates, specific injury or disease that occurred, treatment,
- +36 ;; follow-up, and residuals. If the injury or disease occurred
- +37 ;; BEFORE ACTIVE SERVICE, describe any worsening of residuals due
- +38 ;; to being in military service. Describe current symptoms and
- +39 ;; treatment.
- +40 ;;
- +41 ;;
- +42 ;; 2. Occupational history (for PENSION and INDIVIDUAL UMEMPLOYABILITY
- +43 ;; claims): Obtain the name and address of employers (list most
- +44 ;; current first), type of occupation, employment dates, and wages
- +45 ;; for last 12 months. If any time was lost from work in the past
- +46 ;; 12-month period, please describe the reason and the extent of
- +47 ;; time lost.
- +48 ;;
- +49 ;;
- +50 ;; 3. Describe details of current treatment, conditions being treated,
- +51 ;; and side effects of treatment.
- +52 ;;
- +53 ;;
- +54 ;; 4. Describe all surgery and hospitalizations in and after service
- +55 ;; with approximate dates.
- +56 ;;
- +57 ;;
- +58 ;; 5. If a malignant neoplasm is or was present, provide:
- +59 ;; a. Date of confirmed diagnosis.
- +60 ;;
- +61 ;;
- +62 ;; b. Date of the last surgical, X-ray, antineoplastic chemotherapy,
- +63 ;; radiation, or other therapeutic procedure.
- +64 ;;
- +65 ;;
- +66 ;; c. State expected date treatment regimen is to be completed.
- +67 ;;
- +68 ;;
- +69 ;; d. If treatment is already completed, provide date of last treatment.
- +70 ;;
- +71 ;;
- +72 ;; e. If treatment is already completed, fully describe residuals.
- +73 ;;
- +74 ;;
- +75 ;;
- +76 ;;C. PHYSICAL EXAMINATION (Objective Findings):
- +77 ;;
- +78 ;; Address each of the following and fully describe current findings:
- +79 ;; The examiner should incorporate results of all ancillary studies
- +80 ;; into the final diagnoses.
- +81 ;;
- +82 ;; 1. VS: Heart rate, blood pressure (see #13 below), respirations,
- +83 ;; height, weight, maximum weight in past year, weight change in
- +84 ;; past year, body build, and state of nutrition.
- +85 ;;
- +86 ;;
- +87 ;; 2. DOMINANT HAND: Indicate the dominant hand and how this was
- +88 ;; determined, e.g., writes, eats, combs hair with that hand.
- +89 ;;
- +90 ;;
- +91 ;; 3. POSTURE AND GAIT: Describe abnormality and reason for it.
- +92 ;; Describe any ambulatory aids.
- +93 ;;
- +94 ;;
- +95 ;; 4. SKIN, INCLUDING APPENDAGES: If abnormal, describe appearance,
- +96 ;; location, extent of lesions. If there are laceration or burn
- +97 ;; scars, describe the location, exact measurements (cm. x cm.),
- +98 ;; shape, depression, type of tissue loss, adherence, and tenderness.
- +99 ;; For each burn scar, state if due to a 2nd or 3rd degree burn.
- +100 ;; Describe any limitation of activity or limitation of motion
- +101 ;; due to scarring or other skin lesions.
- +102 ;; NOTE: If there are disfiguring scars (of face, head, or neck),
- +103 ;; obtain COLOR PHOTOGRAPHS of the affected area(s) to submit
- +104 ;; with the examination report.
- +105 ;;
- +106 ;;
- +107 ;; 5. HEMIC AND LYMPHATIC: Describe adenopathy, tenderness,
- +108 ;; suppuration, edema, pallor, etc.
- +109 ;;
- +110 ;;
- +111 ;; 6. HEAD AND FACE: Describe scars, skin lesions, deformities, etc.,
- +112 ;; as discussed under item #4.
- +113 ;;
- +114 ;;
- +115 ;; 7. EYES: Describe external eye, pupil reaction, eye movements.
- +116 ;;
- +117 ;;
- +118 ;; 8. EARS: Describe canals, drums, perforations, discharge.
- +119 ;;
- +120 ;;
- +121 ;; 9. NOSE, SINUSES, MOUTH AND THROAT: Include gross dental findings.
- +122 ;; For sinusitis, describe headaches, pain, episodes of
- +123 ;; incapacitation, frequency and duration of antibiotic treatment.
- +124 ;;
- +125 ;;
- +126 ;; 10. NECK: Describe lymph nodes, thyroid, etc.
- +127 ;;
- +128 ;;
- +129 ;; 11. CHEST: Inspection, palpation, percussion, auscultation. Describe
- +130 ;; respiratory symptoms and effect on daily activities, e.g., how
- +131 ;; far the veteran can walk, how many flights of stairs veteran
- +132 ;; can climb. If a respiratory condition is claimed or suspected,
- +133 ;; refer to appropriate worksheet(s). Most respiratory conditions
- +134 ;; will require PFT's, including post-bronchodilation studies.
- +135 ;; Describe in detail any treatment for pulmonary disease.
- +136 ;;
- +137 ;;
- +138 ;; 12. BREAST: Describe masses, scars, nipple discharge, skin
- +139 ;; abnormalities. Give date of last mammogram, if any. Describe
- +140 ;; any breast surgery (with approximate date) and residuals.
- +141 ;;
- +142 ;;
- +143 ;; 13. CARDIOVASCULAR: NOTE: If there is evidence of a cardiovascular
- +144 ;; disease, or one is claimed, refer to appropriate worksheet(s).
- +145 ;;
- +146 ;; a. Record pulse, quality of heart sounds, abnormal heart sounds,
- +147 ;; arrhythmias. Describe symptoms and treatment for any
- +148 ;; cardiovascular conditions, including peripheral arterial
- +149 ;; and venous disease. Give NYHA classification of heart disease.
- +150 ;; A determination of METS by exercise testing may be required
- +151 ;; for certain cardiovascular conditions, and an estimation of
- +152 ;; METS may be required if exercise testing cannot be conducted
- +153 ;; for medical reasons. (See the cardiovascular worksheet
- +154 ;; for further guidance.)
- +155 ;;
- +156 ;;
- +157 ;; b. Describe the status of peripheral vessels and pulses.
- +158 ;; Describe edema, stasis pigmentation or eczema, ulcers, or
- +159 ;; other skin or nail abnormalities. Describe varicose veins,
- +160 ;; including extent to which any resulting edema is relieved
- +161 ;; by elevation of extremity. Examine for evidence of residuals
- +162 ;; of cold injury when indicated. See and follow special cold
- +163 ;; injury examination worksheet if there is a history of cold
- +164 ;; exposure in service and the special cold injury examination
- +165 ;; has not been previously done.
- +166 ;;
- +167 ;;
- +168 ;; c. BLOOD PRESSURE: (Per the rating schedule, hypertension means
- +169 ;; that the diastolic blood pressure is predominantly 90 mm.
- +170 ;; or greater, and isolated systolic hypertension means that
- +171 ;; the systolic blood pressure is predominantly 160 mm. or
- +172 ;; greater with a diastolic blood pressure of less than 90 mm.)
- +173 ;;
- +174 ;; 1) If the diagnosis of hypertension has not been previously
- +175 ;; established, and it is a claimed issue, B.P. readings
- +176 ;; MUST be taken two or more times on each of at least
- +177 ;; three different days.
- +178 ;;
- +179 ;;
- +180 ;; 2) If hypertension has been previously diagnosed and is
- +181 ;; claimed, but the claimant is not on treatment, B.P.
- +182 ;; readings MUST be taken two or more times on each of
- +183 ;; at least three different days.
- +184 ;;
- +185 ;;
- +186 ;; 3) If hypertension has been previously diagnosed, and the
- +187 ;; claimant is on treatment, take three blood pressure
- +188 ;; readings on the day of the examination.
- +189 ;;TOF