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Routine: DVBCWGX5

DVBCWGX5.m

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  1. DVBCWGX5 ;BPOIFO/RLC - GENERAL MEDICAL WKS TEXT - 2 ; 3/02/2010
  1. ;;2.7;AMIE;**150**;Apr 10, 1995;Build 13
  1. ;
  1. ;
  1. TXT ;
  1. ;; iv. If hypertension has not been claimed, take three blood
  1. ;; pressure readings on the day of the examination. If they
  1. ;; are suggestive of hypertension or are borderline, readings
  1. ;; must be taken two or more times on each of at least two
  1. ;; additional days to rule hypertension in or out.
  1. ;; v. In the diagnostic summary, state whether hypertension is
  1. ;; ruled in or out after completing these B.P. measurements.
  1. ;; If hypertensive heart disease is suspected or found, follow
  1. ;; worksheet for Heart.
  1. ;;
  1. ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
  1. ;; Describe any organ enlargement, ventral hernia, mass,
  1. ;; tenderness, etc.).
  1. ;;
  1. ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
  1. ;; testicles, epididymis, and spermatic cord. If there is a hernia,
  1. ;; describe type, location, size, whether complete, reducible,
  1. ;; recurrent, supported by truss or belt, and whether or not
  1. ;; operable. Describe anal fissures, hemorrhoids, ulcerations,
  1. ;; etc. Include digital exam of rectal walls and prostate.
  1. ;;
  1. ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam, including inspection of
  1. ;; introitus, vagina, and cervix, palpation of labia, vagina,
  1. ;; cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear
  1. ;; if none within past year. If unable to conduct an examination
  1. ;; and Pap smear, or if there is a severe or complex problem
  1. ;; refer to a specialist.
  1. ;;
  1. ;; 17. MUSCULOSKELETAL:
  1. ;; a. For all joint or muscle disorders, state each muscle and
  1. ;; joint affected.
  1. ;;
  1. ;; b. Separately examine and describe in detail each affected joint.
  1. ;; Measure active range of motion in degrees using a goniometer.
  1. ;; State whether there is objective evidence of pain on motion.
  1. ;; After 3 repetitions of the range of motion, state whether there
  1. ;; are additional limitations of range of motion and whether there
  1. ;; is objective evidence of pain on motion. Also state the most
  1. ;; important factor (pain, weakness, fatigue, lack of endurance,
  1. ;; incoordination) for any additional loss of motion after
  1. ;; repetitive motion. Report the range of motion after 3
  1. ;; repetitions. (See the appropriate musculoskeletal worksheet for
  1. ;; more details.)
  1. ;;
  1. ;; c. Describe swelling, effusion, tenderness, muscle spasm, joint
  1. ;; laxity, muscle atrophy, fibrous or bony residual of fracture. If
  1. ;; joint is ankylosed, describe the position and angle of fixation.
  1. ;;
  1. ;; d. If foot problems exist, also describe objective evidence of pain
  1. ;; at rest and on manipulation, rigidity, spasm, circulatory
  1. ;; disturbance, swelling, callus, loss of strength, and whether
  1. ;; condition is acquired or congenital.
  1. ;;
  1. ;; e. If there is amputation of a part, see the appropriate worksheet.
  1. ;;
  1. ;; f. With disc disease, also describe any abnormal neurological
  1. ;; findings and total duration in days or weeks of incapacitating
  1. ;; episodes (an incapacitating episode is a period of acute signs
  1. ;; and symptoms due to intervertebral disc syndrome that requires
  1. ;; bed rest prescribed by a physician and treatment by a physician).
  1. ;;
  1. ;; 18. ENDOCRINE: Describe signs and symptoms of any endocrine disease,
  1. ;; effects on other body systems. See endocrine worksheets for further
  1. ;; guidance.
  1. ;;
  1. ;; 19. NEUROLOGICAL: Assess orientation and memory, gait, stance, and
  1. ;; coordination, cranial nerve functions. Assess deep tendon
  1. ;; reflexes, pain, touch, temperature, vibration, and position,
  1. ;; motor and sensory status of peripheral nerves. If neurological
  1. ;; abnormalities are found on examination, or there is a history
  1. ;; of seizures, refer to appropriate worksheet.
  1. ;;
  1. ;; 20. PSYCHIATRIC: Describe affect, mood, judgment, behavior, compre-
  1. ;; hension of commands, hallucinations or delusions, and intelligence.
  1. ;; (This is meant to be a brief screening examination. If a mental
  1. ;; disorder is claimed, or suspected based on the screening, an
  1. ;; examination for diagnosis and assessment should be conducted by
  1. ;; a psychiatrist or psychologist).
  1. ;;
  1. ;;D. DIAGNOSTIC AND CLINICAL TESTS:
  1. ;;
  1. ;; 1. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;; 2. Review all test results before providing the summary and diagnosis.
  1. ;; 3. Follow additional worksheets, as appropriate.
  1. ;; 4. The diagnosis of degenerative or traumatic arthritis of any joint
  1. ;; requires X-ray confirmation, but once confirmed by X-ray, either
  1. ;; in service or after service, no further X-rays of that joint are
  1. ;; required for disability evaluation purposes.
  1. ;;
  1. ;;E. DIAGNOSIS:
  1. ;;
  1. ;; 1. Provide a summary list of all disabilities diagnosed. Include an
  1. ;; interpretation of the results of all diagnostic and other tests
  1. ;; conducted in the final summary and diagnosis.
  1. ;;
  1. ;; 2. For each condition diagnosed, describe its effect on the veteran's
  1. ;; usual occupation and daily activities.
  1. ;;
  1. ;; 3. CAPACITY TO MANAGE FINANCIAL AFFAIRS: Mental competency, for VA
  1. ;; benefits purposes, refers only to the ability of the veteran to
  1. ;; manage VA benefit payments in his or her own best interest, and not
  1. ;; to any other subject. Mental incompetency, for VA benefits purposes,
  1. ;; means that the veteran, because of injury or disease, is not capable
  1. ;; of managing benefit payments in his or her own best interest. In
  1. ;; order to assist raters in making a legal determination as to
  1. ;; competency, please address the following:
  1. ;;
  1. ;; What is the impact of injury or disease on the veteran's ability
  1. ;; to manage his or her financial affairs, including consideration of
  1. ;; such things as knowing the amount of his or her VA benefit payment,
  1. ;; knowing the amounts and types of bills owed monthly, and handling
  1. ;; the payment prudently? Does the veteran handle the money and pay
  1. ;; the bills himself or herself?
  1. ;;
  1. ;; Based on your examination, do you believe that the veteran is
  1. ;; capable of managing his or her financial affairs? Please provide
  1. ;; examples to support your conclusion.
  1. ;;
  1. ;; If you believe a Social Work Service assessment is needed before
  1. ;; you can give your opinion on the veteran's ability to manage his
  1. ;; or her financial affairs, please explain why.
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END