DVBCWP2 ;ALB/CMM POW, GENERAL WKS TEXT - 2 ; 7 MARCH 1997
;;2.7;AMIE;**12,56**;Apr 10, 1995
;
;
TXT ;
;; 12. BREAST: Comment on any masses palpated in breast parenchyma
;; including axillary tail. Comment on any skin abnormalities.
;; Comment on any discharge from nipples.
;;
;;
;; 13. CARDIOVASCULAR: Record pulse, heart sounds, abnormalities
;; (i.e., arrhythmias, murmurs, etc.), and status of peripheral
;; vessels. Note edema. Describe varicose veins including
;; location, size, extent, ulcers, scars, and competency of deep
;; circulation. Examine for evidence of residuals of frostbite
;; when indicated. See cold injuries examination worksheet.
;; (NOTE: Cardiovascular signs and symptoms should be graded
;; using NYHA scale.)
;;
;;
;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion. If
;; abnormal, describe (i.e., abdominal enlargement, masses,
;; tenderness, etc.).
;;
;;
;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
;; testicles, epididymis, and spermatic cord. (If hernia,
;; describe type, location, size, whether complete, reducible,
;; recurrent, supported by truss or belt, and whether or not
;; operable). Inspection of anus for fissures, hemorrhoids,
;; ulcerations, etc., and digital exam of rectal walls, and
;; prostate.
;;
;;
;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam should include inspection
;; of introitus, vagina, and cervix, palpation of labia, vagina,
;; cervix, uterus, adnexa, and ovaries. Inspection of anus for
;; fissures, hemorrhoids, ulcerations, etc., and digital exam of
;; rectal walls. Any severe abnormalities may be referred to a
;; specialist.
;;
;;
;; 17. MUSCULOSKELETAL: For joint or muscle defects, describe location,
;; swelling, atrophy, tenderness, active and passive motion in
;; degrees using a goniometer, angle of fixation, fracture,
;; fibrous or bony residual, and mechanical aids used by veteran.
;; Provide an assessment of the effect on range of motion and
;; joint function of pain, weakness, fatigue, or incoordination
;; following repetitive use or during flare-ups. (See the
;; appropriate worksheet for more detail.) If foot problems
;; exist, perform above exam and also include objective evidence
;; of pain at rest and on manipulation, rigidity, spasm,
;; circulatory disturbance, swelling, callus, loss of strength,
;; mobility of ankles and feet, and whether acquired or congenital.
;;
;;
;; 18. ENDOCRINE: Describe disease of thyroid, pituitary, adrenals,
;; gonads, other body systems affected, etc.
;;
;;
;; 19. NEUROLOGICAL: Cerebrum - orientation and memory. Cerebellum -
;; gait, stance, coordination. Spinal Cord - deep tendon reflexes,
;; pain, touch, temperature, vibration, position. Cranial
;; nerves - I-XII. If abnormalities are found, describe region
;; of CNS affected.
;;
;;
;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
;; response, emotional reaction, signs of tension and response to
;; social and occupational capacity. State whether the veteran
;; is capable of managing his or her benefit payments in his or
;; her own best interest without restriction. (A physical
;; disability which prevents the veteran from attending to
;; financial matters in person is not a proper basis for a finding
;; of incompetency unless the veteran is, by reason of that
;; disability, incapable of directing someone else in handling
;; the individual's financial affairs.)
;;
;;
;;D. Diagnostic And Clinical Tests:
;;
;; 1. As indicated - e.g., parasite studies, X-rays of joints, etc.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;1. Complete, review and comment on all laboratory and diagnostic tests.
;;
;;2. Provide diagnoses.
;;
;;3. Where some evidence indicates the disability may not have been
;; incurred in service, please provide an opinion as to whether
;; the disease or injury was at least as likely as not incurred
;; in service. Please base your opinion on sound medical reasoning
;; and complete consideration of all the evidence of record.
;; Please discuss your reasoning and the evidence you considered in
;; formulating your opinion.
;;
;;
;;Signature: Date:
;;
;;___________________________________________________________
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWP2 4971 printed Nov 22, 2024@17:03:12 Page 2
DVBCWP2 ;ALB/CMM POW, GENERAL WKS TEXT - 2 ; 7 MARCH 1997
+1 ;;2.7;AMIE;**12,56**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;; 12. BREAST: Comment on any masses palpated in breast parenchyma
+2 ;; including axillary tail. Comment on any skin abnormalities.
+3 ;; Comment on any discharge from nipples.
+4 ;;
+5 ;;
+6 ;; 13. CARDIOVASCULAR: Record pulse, heart sounds, abnormalities
+7 ;; (i.e., arrhythmias, murmurs, etc.), and status of peripheral
+8 ;; vessels. Note edema. Describe varicose veins including
+9 ;; location, size, extent, ulcers, scars, and competency of deep
+10 ;; circulation. Examine for evidence of residuals of frostbite
+11 ;; when indicated. See cold injuries examination worksheet.
+12 ;; (NOTE: Cardiovascular signs and symptoms should be graded
+13 ;; using NYHA scale.)
+14 ;;
+15 ;;
+16 ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion. If
+17 ;; abnormal, describe (i.e., abdominal enlargement, masses,
+18 ;; tenderness, etc.).
+19 ;;
+20 ;;
+21 ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
+22 ;; testicles, epididymis, and spermatic cord. (If hernia,
+23 ;; describe type, location, size, whether complete, reducible,
+24 ;; recurrent, supported by truss or belt, and whether or not
+25 ;; operable). Inspection of anus for fissures, hemorrhoids,
+26 ;; ulcerations, etc., and digital exam of rectal walls, and
+27 ;; prostate.
+28 ;;
+29 ;;
+30 ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam should include inspection
+31 ;; of introitus, vagina, and cervix, palpation of labia, vagina,
+32 ;; cervix, uterus, adnexa, and ovaries. Inspection of anus for
+33 ;; fissures, hemorrhoids, ulcerations, etc., and digital exam of
+34 ;; rectal walls. Any severe abnormalities may be referred to a
+35 ;; specialist.
+36 ;;
+37 ;;
+38 ;; 17. MUSCULOSKELETAL: For joint or muscle defects, describe location,
+39 ;; swelling, atrophy, tenderness, active and passive motion in
+40 ;; degrees using a goniometer, angle of fixation, fracture,
+41 ;; fibrous or bony residual, and mechanical aids used by veteran.
+42 ;; Provide an assessment of the effect on range of motion and
+43 ;; joint function of pain, weakness, fatigue, or incoordination
+44 ;; following repetitive use or during flare-ups. (See the
+45 ;; appropriate worksheet for more detail.) If foot problems
+46 ;; exist, perform above exam and also include objective evidence
+47 ;; of pain at rest and on manipulation, rigidity, spasm,
+48 ;; circulatory disturbance, swelling, callus, loss of strength,
+49 ;; mobility of ankles and feet, and whether acquired or congenital.
+50 ;;
+51 ;;
+52 ;; 18. ENDOCRINE: Describe disease of thyroid, pituitary, adrenals,
+53 ;; gonads, other body systems affected, etc.
+54 ;;
+55 ;;
+56 ;; 19. NEUROLOGICAL: Cerebrum - orientation and memory. Cerebellum -
+57 ;; gait, stance, coordination. Spinal Cord - deep tendon reflexes,
+58 ;; pain, touch, temperature, vibration, position. Cranial
+59 ;; nerves - I-XII. If abnormalities are found, describe region
+60 ;; of CNS affected.
+61 ;;
+62 ;;
+63 ;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
+64 ;; response, emotional reaction, signs of tension and response to
+65 ;; social and occupational capacity. State whether the veteran
+66 ;; is capable of managing his or her benefit payments in his or
+67 ;; her own best interest without restriction. (A physical
+68 ;; disability which prevents the veteran from attending to
+69 ;; financial matters in person is not a proper basis for a finding
+70 ;; of incompetency unless the veteran is, by reason of that
+71 ;; disability, incapable of directing someone else in handling
+72 ;; the individual's financial affairs.)
+73 ;;
+74 ;;
+75 ;;D. Diagnostic And Clinical Tests:
+76 ;;
+77 ;; 1. As indicated - e.g., parasite studies, X-rays of joints, etc.
+78 ;; 2. Include results of all diagnostic and clinical tests conducted
+79 ;; in the examination report.
+80 ;;
+81 ;;
+82 ;;E. Diagnosis:
+83 ;;
+84 ;;1. Complete, review and comment on all laboratory and diagnostic tests.
+85 ;;
+86 ;;2. Provide diagnoses.
+87 ;;
+88 ;;3. Where some evidence indicates the disability may not have been
+89 ;; incurred in service, please provide an opinion as to whether
+90 ;; the disease or injury was at least as likely as not incurred
+91 ;; in service. Please base your opinion on sound medical reasoning
+92 ;; and complete consideration of all the evidence of record.
+93 ;; Please discuss your reasoning and the evidence you considered in
+94 ;; formulating your opinion.
+95 ;;
+96 ;;
+97 ;;Signature: Date:
+98 ;;
+99 ;;___________________________________________________________
+100 ;;END
