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 Apr 09, 2024@20:45:42 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
