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Routine: DVBCWPA5

DVBCWPA5.m

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DVBCWPA5 ;ALB/RLC POW, GENERAL WKS TEXT - 2 ; 7 MARCH 1997

 ;;2.7;AMIE;**183**;Apr 10, 1995;Build 8

 ;

 ;

TXT ;

 ;;   12.  CARDIAC:  Record heart sounds, including any extra heart sounds,

 ;;        rhythm, PMI.  Indicate if there is evidence of congestive heart

 ;;        failure or pulmonary hypertension.  (NOTE:  A determination of METs

 ;;        by exercise testing may be required for certain cardiovascular

 ;;        conditions, and an estimation of METs may be required if exercise

 ;;        testing cannot be conducted for medical reasons.  If there is evidence

 ;;        of a cardiovascular condition, or one is claimed, refer to appropriate

 ;;        worksheets.).

 ;;

 ;;   13.  ABDOMEN/GASTROINTESTINAL:  Report abnormal bowel sounds, ascites, mass,

 ;;        tenderness, guarding, splenomegaly, hepatomegaly, etc.  If there is a

 ;;        hernia, describe type, location, size, whether complete, reducible,

 ;;        recurrent, supported by truss or belt, and whether or not operable.

 ;;        If there are hemorrhoids, state whether they are internal or external,

 ;;        whether bleeding or prolapse (state whether reducible) is present, and

 ;;        whether thrombosis or fissure is present.  If there are periods of

 ;;        incapacitation due to a gastrointestinal condition, state total number

 ;;        of days of incapacitation (requiring bedrest and treatment by a

 ;;        physician) during the past 12-month period.

 ;;

 ;;   14.  GENITOURINARY:  For males, report abnormality of penis, testicles,

 ;;        epididymis, seminal vesicles, spermatic cord and prostate gland.

 ;;        Include rectal examination.  For males and females, if there is a

 ;;        urinary fistula, describe extent of leakage and need for catheter or

 ;;        number of absorbent pads required per day.

 ;;   

 ;;   15.  GYNECOLOGIC:  Report abnormality on pelvic examination of labia,

 ;;        introitus, vagina, cervix, uterus, adnexa and ovaries.  Perform 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.

 ;;

 ;;   16.  MUSCULOSKELETAL:  If there is limitation of motion of one or more

 ;;        joints, a detailed assessment of each affected joint is required.

 ;;        Using a goniometer, measure the active range of motion in degrees.

 ;;        State whether there is objective evidence of pain on motion.  After at

 ;;        least 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 the repetitions.  (See the appropriate

 ;;        musculoskeletal worksheet (feet, spine, etc.) for more details.)

 ;;

 ;;        Describe spasm, atrophy, or other muscle abnormalities.  For atrophy,

 ;;        report measurements bilaterally.  Report any loss of muscle strength

 ;;        using the standard muscle strength grading system (0 = absent.  No

 ;;        muscle movement felt; 1 = trace.  Muscle can be felt to tighten, but

 ;;        no movement produced; 2 = poor.  Muscle movement produced only with

 ;;        gravity eliminated; 3 = fair.  Muscle movement produced against

 ;;        gravity but cannot overcome resistance; 4 = good.  Muscle movement

 ;;        produced against some resistance, but not against "normal" resistance;

 ;;        5 = normal.  Muscle movement can overcome "normal" resistance.).

 ;;

 ;;        If there has been a fracture, describe location and any residuals,

 ;;        such as malunion, deformity, ankylosis, etc.  If there has been an

 ;;        amputation, follow the Residuals of Amputation worksheet.

 ;;

 ;;        If foot problems exist, also report painful motion, swelling, callus,

 ;;        tenderness, instability, weakness, spasm, rigidity, and circulatory

 ;;        disturbance.  Report foot or toe deformities such as pes cavus,

 ;;        hammertoes, or hallux valgus.  If there is flatfoot:  report whether

 ;;        there is pronation; the status of the arch; whether the weight bearing

 ;;        line is over or medial to the great toe; the Achilles, forefoot, and

 ;;        midfoot alignment; whether there is pain at rest or on manipulation;

 ;;        and whether a malalignment is correctable by manipulation.

 ;;

 ;;   17.  EXTREMITIES:  Describe abnormalities such as ulcers, cyanosis,

 ;;        clubbing, stasis dermatitis, gangrene, trophic changes, varicose veins,

 ;;        calf tenderness, edema, and decreased or absent pulses.  If there is

 ;;        edema, is it relieved by elevation of extremities?

 ;;

 ;;   18.  ENDOCRINE:  Describe neck mass or nodule, lid lag or exophthalmos,

 ;;        abnormalities of hair or skin, or abnormalities of other body systems

 ;;        due to endocrine disease.

 ;; 

 ;;   19.  NEUROLOGICAL:  Assess orientation and memory, gait, stance, and 

 ;;        coordination, speech, 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, comprehension

 ;;        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 examination, request a

 ;;        mental disorder or PTSD examination conducted by a specialist.

 ;;

 ;;   21.  BREAST:  Describe mass or diffuse nodularity, nipple abnormalities,

 ;;        gynecomastia, residuals of surgery, axillary lymphadenopathy, and skin

 ;;        abnormalities.  Report whether there is a significant difference in

 ;;        size or contour between the breasts.

 ;;

 ;;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.  Request tests as indicated - e.g., parasite studies, X-rays of joints,

 ;;        etc.  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.  All laboratory and diagnostic tests should be completed and reviewed

 ;;        prior to completing the summary of findings.

 ;;    2.  The POW Physician Coordinator should complete summary of findings,

 ;;        diagnoses, and recommendations.  The Coordinator should also express

 ;;        an opinion, with supporting reasons, concerning the relationship

 ;;        between the veteran's experiences as a POW and each current medical

 ;;        condition.  If osteoarthritis is diagnosed, it should be clarified

 ;;        whether this is post-traumatic osteoarthritis, and, if so, whether it

 ;;        is related to the period of confinement.

 ;;    3.  State whether any specialist examinations are indicated and whether

 ;;        any have been requested.

 ;;    4.  For each condition diagnosed, describe its effect on the veteran's

 ;;        usual occupation and daily activities.

 ;;    5.  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