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Routine: DVBCWGX4

DVBCWGX4.m

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DVBCWGX4 ;BPOIFO/RLC - GENERAL MEDICAL WKS TEXT - 1 ; 3/02/2010

 ;;2.7;AMIE;**150**;Apr 10, 1995;Build 13

 ;

 ;

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.

 ;;

 ;;    2.  If there are flareups of any joint (including of spine, hands, and

 ;;        feet) or muscle disease, state the frequency, duration,

 ;;        precipitating factors, alleviating factors, and the extent, if

 ;;        any, per veteran, they result in additional limitation of motion

 ;;        or other functional impairment during the flareup.

 ;;

 ;;    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 neoplasm is or was present, state whether benign or malignant

 ;;        and provide:

 ;;        a.  Exact diagnosis and date of confirmed diagnosis.

 ;;        b.  Location of neoplasm.

 ;;        c.  Types and dates of treatment.

 ;;        d.  For malignant neoplasm, also state exact date of the last

 ;;            surgical, X-ray, antineoplastic chemotherapy, radiation, or

 ;;            other therapeutic procedure.

 ;;        e.  If treatment is already completed, provide date of last treat-

 ;;             ment, and fully describe residuals.  If not completed, state

 ;;              expected date of completion.

 ;;

 ;;

 ;;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 and name the condition requiring the

 ;;        ambulatory aid(s).

 ;;

 ;;    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.

 ;;        See the Scars worksheet for furthur guidance.  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 Skin.

 ;;

 ;;    7.  EYES:  Describe external eye, pupil reaction, eye movements.  State

 ;;        corrected visual acuity and gross visual field assessment.

 ;;

 ;;    8.  EARS:  Describe canals, drums, perforations, discharge.  State

 ;;        whether hearing is grossly normal or abnormal.  Is there a current

 ;;        complaint of tinnitus?  If so, do you believe it is related to a

 ;;        current medical or psychological problem, or is the etiology

 ;;        unknown without further information?

 ;;

 ;;    9.  NOSE, SINUSES, MOUTH AND THROAT:  Include gross dental findings.

 ;;        For sinusitis, describe headaches, pain, incapacitating (meaning

 ;;        an episode of sinusitis that requires bed rest and treat-ment by

 ;;        a physician with 4-6 weeks of antibiotic treatment), and non-

 ;;        incapacitating episodes of sinusitis during the past 12-month

 ;;        period, 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.

 ;;

 ;;   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.  Report heart size and how determined.

 ;;            (See the cardiovascular worksheets 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.)

 ;;

 ;;            i.  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.

 ;;           ii.  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.

 ;;          iii.  If hypertension has been previously diagnosed, and the

 ;;                claimant is on treatment, take three blood pressure 

 ;;                readings on the day of the examination.

 ;;