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Routine: DVBCWGX4

DVBCWGX4.m

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  1. DVBCWGX4 ;BPOIFO/RLC - GENERAL MEDICAL WKS TEXT - 1 ; 3/02/2010
  1.  ;;2.7;AMIE;**150**;Apr 10, 1995;Build 13
  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.  ;;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.
  1.  ;;
  1.  ;;    2.  If there are flareups of any joint (including of spine, hands, and
  1.  ;;        feet) or muscle disease, state the frequency, duration,
  1.  ;;        precipitating factors, alleviating factors, and the extent, if
  1.  ;;        any, per veteran, they result in additional limitation of motion
  1.  ;;        or other functional impairment during the flareup.
  1.  ;;
  1.  ;;    3.  Describe details of current treatment, conditions being treated,
  1.  ;;        and side effects of treatment.
  1.  ;;
  1.  ;;    4.  Describe all surgery and hospitalizations in and after service
  1.  ;;        with approximate dates.
  1.  ;;
  1.  ;;    5.  If a neoplasm is or was present, state whether benign or malignant
  1.  ;;        and provide:
  1.  ;;        a.  Exact diagnosis and date of confirmed diagnosis.
  1.  ;;        b.  Location of neoplasm.
  1.  ;;        c.  Types and dates of treatment.
  1.  ;;        d.  For malignant neoplasm, also state exact date of the last
  1.  ;;            surgical, X-ray, antineoplastic chemotherapy, radiation, or
  1.  ;;            other therapeutic procedure.
  1.  ;;        e.  If treatment is already completed, provide date of last treat-
  1.  ;;             ment, and fully describe residuals.  If not completed, state
  1.  ;;              expected date of completion.
  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.  ;;    2.  DOMINANT HAND:  Indicate the dominant hand and how this was
  1.  ;;        determined, e.g., writes, eats, combs hair with that hand.
  1.  ;;
  1.  ;;    3.  POSTURE AND GAIT:  Describe abnormality and reason for it.
  1.  ;;        Describe any ambulatory aids and name the condition requiring the
  1.  ;;        ambulatory aid(s).
  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.  ;;        See the Scars worksheet for furthur guidance.  Describe any
  1.  ;;        limitation of activity or limitation of motion due to scarring or
  1.  ;;        other skin lesions.  NOTE:  If there are disfiguring scars (of face,
  1.  ;;        head, or neck), obtain color photographs of the affected area(s) to
  1.  ;;        submit with the examination report.
  1.  ;;
  1.  ;;    5.  HEMIC AND LYMPHATIC:  Describe adenopathy, tenderness,
  1.  ;;        suppuration, edema, pallor, etc.
  1.  ;;
  1.  ;;    6.  HEAD AND FACE:  Describe scars, skin lesions, deformities, etc.,
  1.  ;;        as discussed under Skin.
  1.  ;;
  1.  ;;    7.  EYES:  Describe external eye, pupil reaction, eye movements.  State
  1.  ;;        corrected visual acuity and gross visual field assessment.
  1.  ;;
  1.  ;;    8.  EARS:  Describe canals, drums, perforations, discharge.  State
  1.  ;;        whether hearing is grossly normal or abnormal.  Is there a current
  1.  ;;        complaint of tinnitus?  If so, do you believe it is related to a
  1.  ;;        current medical or psychological problem, or is the etiology
  1.  ;;        unknown without further information?
  1.  ;;
  1.  ;;    9.  NOSE, SINUSES, MOUTH AND THROAT:  Include gross dental findings.
  1.  ;;        For sinusitis, describe headaches, pain, incapacitating (meaning
  1.  ;;        an episode of sinusitis that requires bed rest and treat-ment by
  1.  ;;        a physician with 4-6 weeks of antibiotic treatment), and non-
  1.  ;;        incapacitating episodes of sinusitis during the past 12-month
  1.  ;;        period, frequency and duration of antibiotic treatment.
  1.  ;;
  1.  ;;   10.  NECK:  Describe lymph nodes, thyroid, etc.
  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.  ;;
  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.  ;;   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.  Report heart size and how determined.
  1.  ;;            (See the cardiovascular worksheets for further guidance.)
  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.  ;;        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.  ;;            i.  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.  ;;           ii.  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.  ;;          iii.  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.  ;;