DVBCWGX2 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**26**;Apr 10, 1995
;
;
TXT ;
;; 4) If hypertension has not been claimed, take three blood
;; pressure readings on the day of the examination. If they
;; are suggestive of hypertension or are borderline, readings
;; MUST be taken two or more times on each of at least two
;; additional days to rule hypertension in or out.
;;
;;
;; 5) In the diagnostic summary, state whether hypertension is
;; ruled in or out after completing these B.P. measurements.
;; Describe treatment for hypertension and side effects. If
;; hypertensive heart disease is suspected or found, follow
;; worksheet for Heart.
;;
;;
;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
;; Describe any organ enlargement, ventral hernia, mass,
;; tenderness, etc.).
;;
;;
;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
;; testicles, epididymis, and spermatic cord. If there is a hernia,
;; describe type, location, size, whether complete, reducible,
;; recurrent, supported by truss or belt, and whether or not
;; operable. Describe anal fissures, hemorrhoids, ulcerations,
;; etc. Include digital exam of rectal walls and prostate.
;;
;;
;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam, including inspection of
;; introitus, vagina, and cervix, palpation of labia, vagina,
;; cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear
;; if none within past year. If unable to conduct an examination
;; and Pap smear, or if there is a severe or complex problem
;; refer to a specialist to complete the examination.
;;
;;
;; 17. MUSCULOSKELETAL:
;; a. For all joint or muscle disorders, state each muscle and
;; joint affected.
;;
;;
;; b. Separately examine and describe in detail each affected joint.
;; Measure active and passive range of motion in degrees using a
;; goniometer. In addition, 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 musculoskeletal worksheet for more detail.)
;; NOTE: The diagnosis of DEGENERATIVE OR TRAUMATIC ARTHRITIS OF
;; ANY JOINT REQUIRES X-RAY CONFIRMATION, but once confirmed by
;; X-ray, either in service or after service, no further X-rays
;; of that joint are required for disability evaluation purposes.
;;
;;
;; c. Describe swelling, effusion, tenderness, muscle spasm, joint
;; laxity, muscle atrophy, fibrous or bony residual of fracture. If
;; joint is ankylosed, describe the position and angle of fixation.
;;
;;
;; d. Describe any mechanical aids used by veteran.
;;
;;
;; e. If foot problems exit, also describe objective evidence of pain
;; at rest and on manipulation, rigidity, spasm, circulatory
;; disturbance, swelling, callus, loss of strength, and whether
;; condition is acquired or congenital.
;;
;;
;; f. If there is amputation of a part, see the appropriate worksheet.
;;
;;
;; g. With disc disease, also describe any neurological findings.
;;
;;
;;
;; 18. ENDOCRINE: Describe signs and symptoms of any endocrine disease,
;; effects on other body systems, and current and past treatment.
;; See endocrine worksheets for further guidance.
;;
;;
;; 19. NEUROLOGICAL: Assess orientation and memory, gait, stance, and
;; coordination, cranial nerve functions. Assess deep tendon
;; reflexes, pain, touch, temperature, vibration, and position,
;; motor and sensory status of peripheral nerves. If neurological
;; abnormalities are found on examination, or there is a history
;; of seizures, refer to appropriate worksheet.
;;
;;
;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
;; response, emotional reaction, signs of tension and effects on
;; social and occupational functioning. (This is meant to be a
;; brief screening examination. If a mental disorder is CLAIMED,
;; OR SUSPECTED BASED ON THE SCREENING, an examination for diagnosis
;; and assessment should be conducted by a psychiatrist or
;; psychologist). State whether the veteran is capable of managing
;; his or her benefit payments in his or her own best interests
;; 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. Review all test results before providing the summary and diagnosis.
;; 3. Follow additional worksheets, as appropriate.
;;
;;
;;
;;E. DIAGNOSIS: Provide a summary list of all disabilities diagnosed.
;; Include an interpretation of the results of all diagnostic and other
;; tests conducted in the final summary and diagnosis. For each
;; condition diagnosed, describe its effect on the veteran's usual
;; occupation and daily activities.
;;TOF
;;E. DIAGNOSIS:
;;
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWGX2 6018 printed Oct 16, 2024@17:52:19 Page 2
DVBCWGX2 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
+1 ;;2.7;AMIE;**26**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;; 4) If hypertension has not been claimed, take three blood
+2 ;; pressure readings on the day of the examination. If they
+3 ;; are suggestive of hypertension or are borderline, readings
+4 ;; MUST be taken two or more times on each of at least two
+5 ;; additional days to rule hypertension in or out.
+6 ;;
+7 ;;
+8 ;; 5) In the diagnostic summary, state whether hypertension is
+9 ;; ruled in or out after completing these B.P. measurements.
+10 ;; Describe treatment for hypertension and side effects. If
+11 ;; hypertensive heart disease is suspected or found, follow
+12 ;; worksheet for Heart.
+13 ;;
+14 ;;
+15 ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
+16 ;; Describe any organ enlargement, ventral hernia, mass,
+17 ;; tenderness, etc.).
+18 ;;
+19 ;;
+20 ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
+21 ;; testicles, epididymis, and spermatic cord. If there is a hernia,
+22 ;; describe type, location, size, whether complete, reducible,
+23 ;; recurrent, supported by truss or belt, and whether or not
+24 ;; operable. Describe anal fissures, hemorrhoids, ulcerations,
+25 ;; etc. Include digital exam of rectal walls and prostate.
+26 ;;
+27 ;;
+28 ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam, including inspection of
+29 ;; introitus, vagina, and cervix, palpation of labia, vagina,
+30 ;; cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear
+31 ;; if none within past year. If unable to conduct an examination
+32 ;; and Pap smear, or if there is a severe or complex problem
+33 ;; refer to a specialist to complete the examination.
+34 ;;
+35 ;;
+36 ;; 17. MUSCULOSKELETAL:
+37 ;; a. For all joint or muscle disorders, state each muscle and
+38 ;; joint affected.
+39 ;;
+40 ;;
+41 ;; b. Separately examine and describe in detail each affected joint.
+42 ;; Measure active and passive range of motion in degrees using a
+43 ;; goniometer. In addition, provide an assessment of the effect
+44 ;; on range of motion and joint function of pain, weakness, fatigue,
+45 ;; or incoordination following repetitive use or during flare-ups.
+46 ;; (See the appropriate musculoskeletal worksheet for more detail.)
+47 ;; NOTE: The diagnosis of DEGENERATIVE OR TRAUMATIC ARTHRITIS OF
+48 ;; ANY JOINT REQUIRES X-RAY CONFIRMATION, but once confirmed by
+49 ;; X-ray, either in service or after service, no further X-rays
+50 ;; of that joint are required for disability evaluation purposes.
+51 ;;
+52 ;;
+53 ;; c. Describe swelling, effusion, tenderness, muscle spasm, joint
+54 ;; laxity, muscle atrophy, fibrous or bony residual of fracture. If
+55 ;; joint is ankylosed, describe the position and angle of fixation.
+56 ;;
+57 ;;
+58 ;; d. Describe any mechanical aids used by veteran.
+59 ;;
+60 ;;
+61 ;; e. If foot problems exit, also describe objective evidence of pain
+62 ;; at rest and on manipulation, rigidity, spasm, circulatory
+63 ;; disturbance, swelling, callus, loss of strength, and whether
+64 ;; condition is acquired or congenital.
+65 ;;
+66 ;;
+67 ;; f. If there is amputation of a part, see the appropriate worksheet.
+68 ;;
+69 ;;
+70 ;; g. With disc disease, also describe any neurological findings.
+71 ;;
+72 ;;
+73 ;;
+74 ;; 18. ENDOCRINE: Describe signs and symptoms of any endocrine disease,
+75 ;; effects on other body systems, and current and past treatment.
+76 ;; See endocrine worksheets for further guidance.
+77 ;;
+78 ;;
+79 ;; 19. NEUROLOGICAL: Assess orientation and memory, gait, stance, and
+80 ;; coordination, cranial nerve functions. Assess deep tendon
+81 ;; reflexes, pain, touch, temperature, vibration, and position,
+82 ;; motor and sensory status of peripheral nerves. If neurological
+83 ;; abnormalities are found on examination, or there is a history
+84 ;; of seizures, refer to appropriate worksheet.
+85 ;;
+86 ;;
+87 ;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
+88 ;; response, emotional reaction, signs of tension and effects on
+89 ;; social and occupational functioning. (This is meant to be a
+90 ;; brief screening examination. If a mental disorder is CLAIMED,
+91 ;; OR SUSPECTED BASED ON THE SCREENING, an examination for diagnosis
+92 ;; and assessment should be conducted by a psychiatrist or
+93 ;; psychologist). State whether the veteran is capable of managing
+94 ;; his or her benefit payments in his or her own best interests
+95 ;; without restriction. (A physical disability which prevents the
+96 ;; veteran from attending to financial matters in person is not a
+97 ;; proper basis for a finding of incompetency unless the veteran is,
+98 ;; by reason of that disability, incapable of directing someone
+99 ;; else in handling the individual's financial affairs).
+100 ;;
+101 ;;
+102 ;;
+103 ;;D. DIAGNOSTIC AND CLINICAL TESTS:
+104 ;;
+105 ;; 1. Include results of all diagnostic and clinical tests conducted
+106 ;; in the examination report.
+107 ;; 2. Review all test results before providing the summary and diagnosis.
+108 ;; 3. Follow additional worksheets, as appropriate.
+109 ;;
+110 ;;
+111 ;;
+112 ;;E. DIAGNOSIS: Provide a summary list of all disabilities diagnosed.
+113 ;; Include an interpretation of the results of all diagnostic and other
+114 ;; tests conducted in the final summary and diagnosis. For each
+115 ;; condition diagnosed, describe its effect on the veteran's usual
+116 ;; occupation and daily activities.
+117 ;;TOF
+118 ;;E. DIAGNOSIS:
+119 ;;
+120 ;;
+121 ;;
+122 ;;Signature: Date:
+123 ;;END
