DVBCWHE1 ;ALB/JFP HEART WKS TEXT - 1 ; 12 FEB 1998
;;2.7;AMIE;**16**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;; Comment on:
;; 1. Past history - describe onset of disorder and frequency of
;; cardiac symptoms, including angina, dyspnea, fatigue,
;; dizziness, and syncope. Record dates and severity of
;; episodes of acute cardiac illness, including myocardial
;; infarction, congestive heart failure, and acute rheumatic
;; heart disease. Describe all cardiac surgery, including
;; coronary artery bypass, valvular surgery, cardiac transplant,
;; and angioplasty.
;; 2. Current treatment - type, dosage, response, and side effects.
;; 3. With the exceptions given below, examinations for valvular
;; heart disease, endocarditis, pericarditis, pericardial
;; adhesions, syphilitic heart disease, arteriosclerotic heart
;; disease, myocardial infarction, hypertensive heart disease,
;; heart valve replacement, coronary bypass sugery, cardiac
;; transplanation, and cardiomyopathy, require the examiner to
;; provide the METs level, determine by exercise testing, at
;; which symptoms of dyspnea, fatigue, angina, dizziness, or
;; syncope result.
;; 4. Exercise testing is not required for the above listed
;; conditions in the following circumstances:
;; a. If exercise testing is medically contraindicated:
;; 1) In that case, provide the medical reason exercise
;; testing cannot be conducted, and
;; 2) Provide an estimate of the level of activity
;; (expressed in METs and supported by specific
;; examples, such as slow stair climbing, or shoveling
;; snow) that results in dyspnea, fatigue, angina,
;; dizziness, or syncope.
;; b. If left ventricular dysfunction is present, and the
;; ejection fraction is 50 percent or less.
;; c. If there is chronic congestive heart failure or there has
;; been more than one episode of acute congestive heart
;; failure in the past year.
;; d. With valvular heart disease - during active infection
;; with valvular heart damage and for three months following
;; cessation of therapy for the active infection.
;; e. With endocarditis - for three months following cessation
;; of therapy for active infection with cardiac involvement.
;; f. With pericarditis - for three months following cessation
;; of therapy for active infection with cardiac involvement.
;; g. With myocardial infarction - for three months following
;; myocardial infarction.
;; h. With valve replacement - for six months following date of
;; hospital admission for valve replacement.
;; i. With coronary bypass surgery - for three months following
;; hospital admission for surgery.
;; j. For cardiac transplantation - for indefinite period from
;; date of hospital admission for cardiac transplantation.
;; k. If an exercise test has been done within the past year,
;; the results are of record, and there is no indication
;; that there has been a change in the cardiac status of the
;; veteran since.
;; 5. For hyperthyroid heart disease, if atrial fibrillation is
;; present, use arrhythmia worksheet. Also use endocrine
;; worksheet if examining for hyperthyroidism.
;; 6. Describe the effects of the condition on the veteran's usual
;; occupation and daily activities.
;; 7. Even when special examinations and tests (e.g., exercise
;; testing) are not required under the worksheet guidelines, they
;; may be requested or conducted at the discretion of the
;; examiner, when the examiner believes that the available
;; information does not fully reflect the severity of the
;; veteran's cardiovascular disability.
;;
;;C. Physical Examination (Objective Findings):
;; Address each of the following and fully describe current findings:
;; 1. Heart size and method of determination, heart rhythm and rate,
;; heart sounds, blood pressure.
;; 2. Evidence of congestive heart failure - rales, edema, liver
;; enlargement, etc.
;;
;;D. Diagnostic and Clinical Tests:
;; 1. Chest X-ray, EKG, exercise stress test, echocardiogram,
;; Holter monitor, thallium study, angiography, etc., as
;; appropriate, and as required or indicated.
;; 2. Include results of all diagnostic and clinical tests
;; conducted in the examination report, including status of left
;; ventricular function, if measured.
;; 3. Valvular heart disease and endocarditis require documentation
;; of diagnosis by physical findings and either echocardiogram,
;; Doppler echocardiogram, or cardiac catheterization, if not
;; already of record.
;; 4. Other types of heart disease must be documented by appropriate
;; objective diagnostic tests.
;;
;;E. Diagnosis and Opinion:
;; 1. Type of heart disease and etiology, if known.
;; 2. Type of surgery, if any, and results.
;; 3. If the veteran is service-connected for rheumatic heart
;; disease and later develops non-service-connected
;; arteriosclerotic heart disease, state, if possible, which
;; cardiac findings can be attributed to each condition. If it
;; is not possible to separate the signs and symptoms of one
;; from the other, so state, and explain.
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWHE1 6066 printed Nov 22, 2024@17:01:50 Page 2
DVBCWHE1 ;ALB/JFP HEART WKS TEXT - 1 ; 12 FEB 1998
+1 ;;2.7;AMIE;**16**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;; Comment on:
+5 ;; 1. Past history - describe onset of disorder and frequency of
+6 ;; cardiac symptoms, including angina, dyspnea, fatigue,
+7 ;; dizziness, and syncope. Record dates and severity of
+8 ;; episodes of acute cardiac illness, including myocardial
+9 ;; infarction, congestive heart failure, and acute rheumatic
+10 ;; heart disease. Describe all cardiac surgery, including
+11 ;; coronary artery bypass, valvular surgery, cardiac transplant,
+12 ;; and angioplasty.
+13 ;; 2. Current treatment - type, dosage, response, and side effects.
+14 ;; 3. With the exceptions given below, examinations for valvular
+15 ;; heart disease, endocarditis, pericarditis, pericardial
+16 ;; adhesions, syphilitic heart disease, arteriosclerotic heart
+17 ;; disease, myocardial infarction, hypertensive heart disease,
+18 ;; heart valve replacement, coronary bypass sugery, cardiac
+19 ;; transplanation, and cardiomyopathy, require the examiner to
+20 ;; provide the METs level, determine by exercise testing, at
+21 ;; which symptoms of dyspnea, fatigue, angina, dizziness, or
+22 ;; syncope result.
+23 ;; 4. Exercise testing is not required for the above listed
+24 ;; conditions in the following circumstances:
+25 ;; a. If exercise testing is medically contraindicated:
+26 ;; 1) In that case, provide the medical reason exercise
+27 ;; testing cannot be conducted, and
+28 ;; 2) Provide an estimate of the level of activity
+29 ;; (expressed in METs and supported by specific
+30 ;; examples, such as slow stair climbing, or shoveling
+31 ;; snow) that results in dyspnea, fatigue, angina,
+32 ;; dizziness, or syncope.
+33 ;; b. If left ventricular dysfunction is present, and the
+34 ;; ejection fraction is 50 percent or less.
+35 ;; c. If there is chronic congestive heart failure or there has
+36 ;; been more than one episode of acute congestive heart
+37 ;; failure in the past year.
+38 ;; d. With valvular heart disease - during active infection
+39 ;; with valvular heart damage and for three months following
+40 ;; cessation of therapy for the active infection.
+41 ;; e. With endocarditis - for three months following cessation
+42 ;; of therapy for active infection with cardiac involvement.
+43 ;; f. With pericarditis - for three months following cessation
+44 ;; of therapy for active infection with cardiac involvement.
+45 ;; g. With myocardial infarction - for three months following
+46 ;; myocardial infarction.
+47 ;; h. With valve replacement - for six months following date of
+48 ;; hospital admission for valve replacement.
+49 ;; i. With coronary bypass surgery - for three months following
+50 ;; hospital admission for surgery.
+51 ;; j. For cardiac transplantation - for indefinite period from
+52 ;; date of hospital admission for cardiac transplantation.
+53 ;; k. If an exercise test has been done within the past year,
+54 ;; the results are of record, and there is no indication
+55 ;; that there has been a change in the cardiac status of the
+56 ;; veteran since.
+57 ;; 5. For hyperthyroid heart disease, if atrial fibrillation is
+58 ;; present, use arrhythmia worksheet. Also use endocrine
+59 ;; worksheet if examining for hyperthyroidism.
+60 ;; 6. Describe the effects of the condition on the veteran's usual
+61 ;; occupation and daily activities.
+62 ;; 7. Even when special examinations and tests (e.g., exercise
+63 ;; testing) are not required under the worksheet guidelines, they
+64 ;; may be requested or conducted at the discretion of the
+65 ;; examiner, when the examiner believes that the available
+66 ;; information does not fully reflect the severity of the
+67 ;; veteran's cardiovascular disability.
+68 ;;
+69 ;;C. Physical Examination (Objective Findings):
+70 ;; Address each of the following and fully describe current findings:
+71 ;; 1. Heart size and method of determination, heart rhythm and rate,
+72 ;; heart sounds, blood pressure.
+73 ;; 2. Evidence of congestive heart failure - rales, edema, liver
+74 ;; enlargement, etc.
+75 ;;
+76 ;;D. Diagnostic and Clinical Tests:
+77 ;; 1. Chest X-ray, EKG, exercise stress test, echocardiogram,
+78 ;; Holter monitor, thallium study, angiography, etc., as
+79 ;; appropriate, and as required or indicated.
+80 ;; 2. Include results of all diagnostic and clinical tests
+81 ;; conducted in the examination report, including status of left
+82 ;; ventricular function, if measured.
+83 ;; 3. Valvular heart disease and endocarditis require documentation
+84 ;; of diagnosis by physical findings and either echocardiogram,
+85 ;; Doppler echocardiogram, or cardiac catheterization, if not
+86 ;; already of record.
+87 ;; 4. Other types of heart disease must be documented by appropriate
+88 ;; objective diagnostic tests.
+89 ;;
+90 ;;E. Diagnosis and Opinion:
+91 ;; 1. Type of heart disease and etiology, if known.
+92 ;; 2. Type of surgery, if any, and results.
+93 ;; 3. If the veteran is service-connected for rheumatic heart
+94 ;; disease and later develops non-service-connected
+95 ;; arteriosclerotic heart disease, state, if possible, which
+96 ;; cardiac findings can be attributed to each condition. If it
+97 ;; is not possible to separate the signs and symptoms of one
+98 ;; from the other, so state, and explain.
+99 ;;
+100 ;;
+101 ;;Signature: Date:
+102 ;;END
