- DVBCWGX5 ;BPOIFO/RLC - GENERAL MEDICAL WKS TEXT - 2 ; 3/02/2010
- ;;2.7;AMIE;**150**;Apr 10, 1995;Build 13
- ;
- ;
- TXT ;
- ;; iv. 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.
- ;; v. In the diagnostic summary, state whether hypertension is
- ;; ruled in or out after completing these B.P. measurements.
- ;; 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.
- ;;
- ;; 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 range of motion in degrees using a goniometer.
- ;; State whether there is objective evidence of pain on motion.
- ;; After 3 repetitions of the range of motion, state whether there
- ;; are additional limitations of range of motion and whether there
- ;; is objective evidence of pain on motion. Also state the most
- ;; important factor (pain, weakness, fatigue, lack of endurance,
- ;; incoordination) for any additional loss of motion after
- ;; repetitive motion. Report the range of motion after 3
- ;; repetitions. (See the appropriate musculoskeletal worksheet for
- ;; more details.)
- ;;
- ;; 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. If foot problems exist, 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.
- ;;
- ;; e. If there is amputation of a part, see the appropriate worksheet.
- ;;
- ;; f. With disc disease, also describe any abnormal neurological
- ;; findings and total duration in days or weeks of incapacitating
- ;; episodes (an incapacitating episode is a period of acute signs
- ;; and symptoms due to intervertebral disc syndrome that requires
- ;; bed rest prescribed by a physician and treatment by a physician).
- ;;
- ;; 18. ENDOCRINE: Describe signs and symptoms of any endocrine disease,
- ;; effects on other body systems. 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 affect, mood, judgment, behavior, compre-
- ;; hension of commands, hallucinations or delusions, and intelligence.
- ;; (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).
- ;;
- ;;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.
- ;; 4. 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.
- ;;
- ;;E. DIAGNOSIS:
- ;;
- ;; 1. 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.
- ;;
- ;; 2. For each condition diagnosed, describe its effect on the veteran's
- ;; usual occupation and daily activities.
- ;;
- ;; 3. CAPACITY TO MANAGE FINANCIAL AFFAIRS: Mental competency, for VA
- ;; benefits purposes, refers only to the ability of the veteran to
- ;; manage VA benefit payments in his or her own best interest, and not
- ;; to any other subject. Mental incompetency, for VA benefits purposes,
- ;; means that the veteran, because of injury or disease, is not capable
- ;; of managing benefit payments in his or her own best interest. In
- ;; order to assist raters in making a legal determination as to
- ;; competency, please address the following:
- ;;
- ;; What is the impact of injury or disease on the veteran's ability
- ;; to manage his or her financial affairs, including consideration of
- ;; such things as knowing the amount of his or her VA benefit payment,
- ;; knowing the amounts and types of bills owed monthly, and handling
- ;; the payment prudently? Does the veteran handle the money and pay
- ;; the bills himself or herself?
- ;;
- ;; Based on your examination, do you believe that the veteran is
- ;; capable of managing his or her financial affairs? Please provide
- ;; examples to support your conclusion.
- ;;
- ;; If you believe a Social Work Service assessment is needed before
- ;; you can give your opinion on the veteran's ability to manage his
- ;; or her financial affairs, please explain why.
- ;;
- ;;
- ;;Signature: Date:
- ;;END
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWGX5 7297 printed Feb 18, 2025@23:17:57 Page 2
- DVBCWGX5 ;BPOIFO/RLC - GENERAL MEDICAL WKS TEXT - 2 ; 3/02/2010
- +1 ;;2.7;AMIE;**150**;Apr 10, 1995;Build 13
- +2 ;
- +3 ;
- TXT ;
- +1 ;; iv. 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 ;; v. In the diagnostic summary, state whether hypertension is
- +7 ;; ruled in or out after completing these B.P. measurements.
- +8 ;; If hypertensive heart disease is suspected or found, follow
- +9 ;; worksheet for Heart.
- +10 ;;
- +11 ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
- +12 ;; Describe any organ enlargement, ventral hernia, mass,
- +13 ;; tenderness, etc.).
- +14 ;;
- +15 ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
- +16 ;; testicles, epididymis, and spermatic cord. If there is a hernia,
- +17 ;; describe type, location, size, whether complete, reducible,
- +18 ;; recurrent, supported by truss or belt, and whether or not
- +19 ;; operable. Describe anal fissures, hemorrhoids, ulcerations,
- +20 ;; etc. Include digital exam of rectal walls and prostate.
- +21 ;;
- +22 ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam, including inspection of
- +23 ;; introitus, vagina, and cervix, palpation of labia, vagina,
- +24 ;; cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear
- +25 ;; if none within past year. If unable to conduct an examination
- +26 ;; and Pap smear, or if there is a severe or complex problem
- +27 ;; refer to a specialist.
- +28 ;;
- +29 ;; 17. MUSCULOSKELETAL:
- +30 ;; a. For all joint or muscle disorders, state each muscle and
- +31 ;; joint affected.
- +32 ;;
- +33 ;; b. Separately examine and describe in detail each affected joint.
- +34 ;; Measure active range of motion in degrees using a goniometer.
- +35 ;; State whether there is objective evidence of pain on motion.
- +36 ;; After 3 repetitions of the range of motion, state whether there
- +37 ;; are additional limitations of range of motion and whether there
- +38 ;; is objective evidence of pain on motion. Also state the most
- +39 ;; important factor (pain, weakness, fatigue, lack of endurance,
- +40 ;; incoordination) for any additional loss of motion after
- +41 ;; repetitive motion. Report the range of motion after 3
- +42 ;; repetitions. (See the appropriate musculoskeletal worksheet for
- +43 ;; more details.)
- +44 ;;
- +45 ;; c. Describe swelling, effusion, tenderness, muscle spasm, joint
- +46 ;; laxity, muscle atrophy, fibrous or bony residual of fracture. If
- +47 ;; joint is ankylosed, describe the position and angle of fixation.
- +48 ;;
- +49 ;; d. If foot problems exist, also describe objective evidence of pain
- +50 ;; at rest and on manipulation, rigidity, spasm, circulatory
- +51 ;; disturbance, swelling, callus, loss of strength, and whether
- +52 ;; condition is acquired or congenital.
- +53 ;;
- +54 ;; e. If there is amputation of a part, see the appropriate worksheet.
- +55 ;;
- +56 ;; f. With disc disease, also describe any abnormal neurological
- +57 ;; findings and total duration in days or weeks of incapacitating
- +58 ;; episodes (an incapacitating episode is a period of acute signs
- +59 ;; and symptoms due to intervertebral disc syndrome that requires
- +60 ;; bed rest prescribed by a physician and treatment by a physician).
- +61 ;;
- +62 ;; 18. ENDOCRINE: Describe signs and symptoms of any endocrine disease,
- +63 ;; effects on other body systems. See endocrine worksheets for further
- +64 ;; guidance.
- +65 ;;
- +66 ;; 19. NEUROLOGICAL: Assess orientation and memory, gait, stance, and
- +67 ;; coordination, cranial nerve functions. Assess deep tendon
- +68 ;; reflexes, pain, touch, temperature, vibration, and position,
- +69 ;; motor and sensory status of peripheral nerves. If neurological
- +70 ;; abnormalities are found on examination, or there is a history
- +71 ;; of seizures, refer to appropriate worksheet.
- +72 ;;
- +73 ;; 20. PSYCHIATRIC: Describe affect, mood, judgment, behavior, compre-
- +74 ;; hension of commands, hallucinations or delusions, and intelligence.
- +75 ;; (This is meant to be a brief screening examination. If a mental
- +76 ;; disorder is claimed, or suspected based on the screening, an
- +77 ;; examination for diagnosis and assessment should be conducted by
- +78 ;; a psychiatrist or psychologist).
- +79 ;;
- +80 ;;D. DIAGNOSTIC AND CLINICAL TESTS:
- +81 ;;
- +82 ;; 1. Include results of all diagnostic and clinical tests conducted
- +83 ;; in the examination report.
- +84 ;; 2. Review all test results before providing the summary and diagnosis.
- +85 ;; 3. Follow additional worksheets, as appropriate.
- +86 ;; 4. The diagnosis of degenerative or traumatic arthritis of any joint
- +87 ;; requires X-ray confirmation, but once confirmed by X-ray, either
- +88 ;; in service or after service, no further X-rays of that joint are
- +89 ;; required for disability evaluation purposes.
- +90 ;;
- +91 ;;E. DIAGNOSIS:
- +92 ;;
- +93 ;; 1. Provide a summary list of all disabilities diagnosed. Include an
- +94 ;; interpretation of the results of all diagnostic and other tests
- +95 ;; conducted in the final summary and diagnosis.
- +96 ;;
- +97 ;; 2. For each condition diagnosed, describe its effect on the veteran's
- +98 ;; usual occupation and daily activities.
- +99 ;;
- +100 ;; 3. CAPACITY TO MANAGE FINANCIAL AFFAIRS: Mental competency, for VA
- +101 ;; benefits purposes, refers only to the ability of the veteran to
- +102 ;; manage VA benefit payments in his or her own best interest, and not
- +103 ;; to any other subject. Mental incompetency, for VA benefits purposes,
- +104 ;; means that the veteran, because of injury or disease, is not capable
- +105 ;; of managing benefit payments in his or her own best interest. In
- +106 ;; order to assist raters in making a legal determination as to
- +107 ;; competency, please address the following:
- +108 ;;
- +109 ;; What is the impact of injury or disease on the veteran's ability
- +110 ;; to manage his or her financial affairs, including consideration of
- +111 ;; such things as knowing the amount of his or her VA benefit payment,
- +112 ;; knowing the amounts and types of bills owed monthly, and handling
- +113 ;; the payment prudently? Does the veteran handle the money and pay
- +114 ;; the bills himself or herself?
- +115 ;;
- +116 ;; Based on your examination, do you believe that the veteran is
- +117 ;; capable of managing his or her financial affairs? Please provide
- +118 ;; examples to support your conclusion.
- +119 ;;
- +120 ;; If you believe a Social Work Service assessment is needed before
- +121 ;; you can give your opinion on the veteran's ability to manage his
- +122 ;; or her financial affairs, please explain why.
- +123 ;;
- +124 ;;
- +125 ;;Signature: Date:
- +126 ;;END