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Routine: DVBCWGX5

DVBCWGX5.m

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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