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Routine: DVBCWGX1

DVBCWGX1.m

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  1. DVBCWGX1 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
  1. ;;2.7;AMIE;**26**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;NARRATIVE: This is a comprehensive base-line or screening examination for
  1. ;;all body systems, not just specific conditions claimed by the veteran.
  1. ;;It is often the initial post-discharge examination of a veteran requested
  1. ;;by the Compensation and Pension Service for disability compensation
  1. ;;purposes. As a screening examination, it is not meant to elicit the
  1. ;;detailed information about specific conditions that is necessary for rating
  1. ;;purposes. Therefore, all claimed conditions, and any found or suspected
  1. ;;conditions that were not claimed, should be addressed by referring to
  1. ;;and following all appropriate worksheets, in addition to this one, to
  1. ;;assure that the examination for each condition provides information
  1. ;;adequate for rating purposes. This does not require that a medical
  1. ;;specialist conduct examinations based on other worksheets, except in the
  1. ;;case of vision and hearing problems, mental disorders, or especially
  1. ;;complex or unusual problems. VISION, HEARING, AND MENTAL DISORDER
  1. ;;EXAMINATIONS MUST BE CONDUCTED BY A SPECIALIST. The examiner may request
  1. ;;any additional studies or examinations needed for proper diagnosis and
  1. ;;evaluation (see other worksheets for guidance). All important negatives
  1. ;;should be reported. The regional office may also request a general medical
  1. ;;examination as evidence for nonservice-connected disability pension claims
  1. ;;or for claimed entitlement to individual unemployability benefits in
  1. ;;service-connected disability compensation claims. Barring unusual
  1. ;;problems, examinations for pension should generally be adequate if only
  1. ;;this general worksheet is followed.
  1. ;;
  1. ;;
  1. ;;A. REVIEW OF MEDICAL RECORDS: Indicate whether the C-file was reviewed.
  1. ;;
  1. ;;
  1. ;;
  1. ;;B. MEDICAL HISTORY (Subjective Complaints):
  1. ;;
  1. ;; 1. Discuss: Whether an injury or disease that is found OCCURRED
  1. ;; DURING ACTIVE SERVICE, BEFORE ACTIVE SERVICE, OR AFTER ACTIVE
  1. ;; SERVICE. To the extent possible, describe the circumstances,
  1. ;; dates, specific injury or disease that occurred, treatment,
  1. ;; follow-up, and residuals. If the injury or disease occurred
  1. ;; BEFORE ACTIVE SERVICE, describe any worsening of residuals due
  1. ;; to being in military service. Describe current symptoms and
  1. ;; treatment.
  1. ;;
  1. ;;
  1. ;; 2. Occupational history (for PENSION and INDIVIDUAL UMEMPLOYABILITY
  1. ;; claims): Obtain the name and address of employers (list most
  1. ;; current first), type of occupation, employment dates, and wages
  1. ;; for last 12 months. If any time was lost from work in the past
  1. ;; 12-month period, please describe the reason and the extent of
  1. ;; time lost.
  1. ;;
  1. ;;
  1. ;; 3. Describe details of current treatment, conditions being treated,
  1. ;; and side effects of treatment.
  1. ;;
  1. ;;
  1. ;; 4. Describe all surgery and hospitalizations in and after service
  1. ;; with approximate dates.
  1. ;;
  1. ;;
  1. ;; 5. If a malignant neoplasm is or was present, provide:
  1. ;; a. Date of confirmed diagnosis.
  1. ;;
  1. ;;
  1. ;; b. Date of the last surgical, X-ray, antineoplastic chemotherapy,
  1. ;; radiation, or other therapeutic procedure.
  1. ;;
  1. ;;
  1. ;; c. State expected date treatment regimen is to be completed.
  1. ;;
  1. ;;
  1. ;; d. If treatment is already completed, provide date of last treatment.
  1. ;;
  1. ;;
  1. ;; e. If treatment is already completed, fully describe residuals.
  1. ;;
  1. ;;
  1. ;;
  1. ;;C. PHYSICAL EXAMINATION (Objective Findings):
  1. ;;
  1. ;; Address each of the following and fully describe current findings:
  1. ;; The examiner should incorporate results of all ancillary studies
  1. ;; into the final diagnoses.
  1. ;;
  1. ;; 1. VS: Heart rate, blood pressure (see #13 below), respirations,
  1. ;; height, weight, maximum weight in past year, weight change in
  1. ;; past year, body build, and state of nutrition.
  1. ;;
  1. ;;
  1. ;; 2. DOMINANT HAND: Indicate the dominant hand and how this was
  1. ;; determined, e.g., writes, eats, combs hair with that hand.
  1. ;;
  1. ;;
  1. ;; 3. POSTURE AND GAIT: Describe abnormality and reason for it.
  1. ;; Describe any ambulatory aids.
  1. ;;
  1. ;;
  1. ;; 4. SKIN, INCLUDING APPENDAGES: If abnormal, describe appearance,
  1. ;; location, extent of lesions. If there are laceration or burn
  1. ;; scars, describe the location, exact measurements (cm. x cm.),
  1. ;; shape, depression, type of tissue loss, adherence, and tenderness.
  1. ;; For each burn scar, state if due to a 2nd or 3rd degree burn.
  1. ;; Describe any limitation of activity or limitation of motion
  1. ;; due to scarring or other skin lesions.
  1. ;; NOTE: If there are disfiguring scars (of face, head, or neck),
  1. ;; obtain COLOR PHOTOGRAPHS of the affected area(s) to submit
  1. ;; with the examination report.
  1. ;;
  1. ;;
  1. ;; 5. HEMIC AND LYMPHATIC: Describe adenopathy, tenderness,
  1. ;; suppuration, edema, pallor, etc.
  1. ;;
  1. ;;
  1. ;; 6. HEAD AND FACE: Describe scars, skin lesions, deformities, etc.,
  1. ;; as discussed under item #4.
  1. ;;
  1. ;;
  1. ;; 7. EYES: Describe external eye, pupil reaction, eye movements.
  1. ;;
  1. ;;
  1. ;; 8. EARS: Describe canals, drums, perforations, discharge.
  1. ;;
  1. ;;
  1. ;; 9. NOSE, SINUSES, MOUTH AND THROAT: Include gross dental findings.
  1. ;; For sinusitis, describe headaches, pain, episodes of
  1. ;; incapacitation, frequency and duration of antibiotic treatment.
  1. ;;
  1. ;;
  1. ;; 10. NECK: Describe lymph nodes, thyroid, etc.
  1. ;;
  1. ;;
  1. ;; 11. CHEST: Inspection, palpation, percussion, auscultation. Describe
  1. ;; respiratory symptoms and effect on daily activities, e.g., how
  1. ;; far the veteran can walk, how many flights of stairs veteran
  1. ;; can climb. If a respiratory condition is claimed or suspected,
  1. ;; refer to appropriate worksheet(s). Most respiratory conditions
  1. ;; will require PFT's, including post-bronchodilation studies.
  1. ;; Describe in detail any treatment for pulmonary disease.
  1. ;;
  1. ;;
  1. ;; 12. BREAST: Describe masses, scars, nipple discharge, skin
  1. ;; abnormalities. Give date of last mammogram, if any. Describe
  1. ;; any breast surgery (with approximate date) and residuals.
  1. ;;
  1. ;;
  1. ;; 13. CARDIOVASCULAR: NOTE: If there is evidence of a cardiovascular
  1. ;; disease, or one is claimed, refer to appropriate worksheet(s).
  1. ;;
  1. ;; a. Record pulse, quality of heart sounds, abnormal heart sounds,
  1. ;; arrhythmias. Describe symptoms and treatment for any
  1. ;; cardiovascular conditions, including peripheral arterial
  1. ;; and venous disease. Give NYHA classification of heart disease.
  1. ;; A determination of METS by exercise testing may be required
  1. ;; for certain cardiovascular conditions, and an estimation of
  1. ;; METS may be required if exercise testing cannot be conducted
  1. ;; for medical reasons. (See the cardiovascular worksheet
  1. ;; for further guidance.)
  1. ;;
  1. ;;
  1. ;; b. Describe the status of peripheral vessels and pulses.
  1. ;; Describe edema, stasis pigmentation or eczema, ulcers, or
  1. ;; other skin or nail abnormalities. Describe varicose veins,
  1. ;; including extent to which any resulting edema is relieved
  1. ;; by elevation of extremity. Examine for evidence of residuals
  1. ;; of cold injury when indicated. See and follow special cold
  1. ;; injury examination worksheet if there is a history of cold
  1. ;; exposure in service and the special cold injury examination
  1. ;; has not been previously done.
  1. ;;
  1. ;;
  1. ;; c. BLOOD PRESSURE: (Per the rating schedule, hypertension means
  1. ;; that the diastolic blood pressure is predominantly 90 mm.
  1. ;; or greater, and isolated systolic hypertension means that
  1. ;; the systolic blood pressure is predominantly 160 mm. or
  1. ;; greater with a diastolic blood pressure of less than 90 mm.)
  1. ;;
  1. ;; 1) If the diagnosis of hypertension has not been previously
  1. ;; established, and it is a claimed issue, B.P. readings
  1. ;; MUST be taken two or more times on each of at least
  1. ;; three different days.
  1. ;;
  1. ;;
  1. ;; 2) If hypertension has been previously diagnosed and is
  1. ;; claimed, but the claimant is not on treatment, B.P.
  1. ;; readings MUST be taken two or more times on each of
  1. ;; at least three different days.
  1. ;;
  1. ;;
  1. ;; 3) If hypertension has been previously diagnosed, and the
  1. ;; claimant is on treatment, take three blood pressure
  1. ;; readings on the day of the examination.
  1. ;;TOF