DVBCWRM1.m

DVBCWRM1 ;ALB/CMM RESPIRATORY, MISC. DISEASES WKS TEXT - 1 ; 6 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Comment on:

 ;;    1.  Fever and/or night sweats.

 ;;

 ;;

 ;;    2.  Weight loss or gain.

 ;;

 ;;

 ;;    3.  Daytime hypersomnolence.

 ;;

 ;;

 ;;    4.  Hemoptysis.

 ;;

 ;;

 ;;    5.  Describe current treatment such as anticoagulant, tracheostomy,

 ;;        CPAP, oxygen, or antimicrobial therapy.

 ;;

 ;;

 ;;    6.  If malignant disease, state initial treatment date, site of 

 ;;        original tumor, type of tumor, types of treatment used, and 

 ;;        date treatment is expected to end.  If treatment has been 

 ;;        completed, state date treatment was completed.

 ;;

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Address each of the following as appropriate to the condition 

 ;;    being examined and fully describe current findings:

 ;;    1.  Pulmonary Hypertension, RVH, cor pulmonale, or congestive 

 ;;        heart failure.

 ;;

 ;;

 ;;    2.  Residuals of pulmonary embolism.

 ;;

 ;;

 ;;    3.  Respiratory Failure.

 ;;

 ;;

 ;;    4.  Evidence of chronic pulmonary thromboembolism.

 ;;

 ;;

 ;;    5.  If ankylosing spondylitis, is there restriction of the chest 

 ;;        excursion and dyspnea on minimal exertion?

 ;;

 ;;

 ;;    6.  Describe all residuals of malignancy including those due to 

 ;;        treatment.

 ;;

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  Pulmonary Function Tests, if indicated. When the results of 

 ;;        pre-bronchodilator pulmonary function tests are NORMAL, post-

 ;;        bronchodilator studies are not required for VA evaluation 

 ;;        purposes.  IN ALL OTHER CASES, post-bronchodilator studies 

 ;;        should be conducted unless contraindicated (because of allergy

 ;;        to medication, etc.) or if the veteran was on bronchodilators

 ;;        before the test and had taken his or her medication within a 

 ;;        few hours of the study.  An examiner who determines that a 

 ;;        post-bronchodilator study should not be performed should 

 ;;        provide an explanation of why not.  If there is a disparity 

 ;;        between the results of different pulmonary function tests 

 ;;        (FEV-1, FVC, etc.), the examiner should indicate which test 

 ;;        result is the best indicator of the veteran's level of 

 ;;        pulmonary functioning.

 ;;    2.  If sleep apnea is suspected, order SLEEP STUDIES.

 ;;    3.  Chest X-ray if necessary to document sarcoidosis or other 

 ;;        parenchymal disease.

 ;;    4.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCWRM1   2945     printed  Feb 18, 2025@23:20:12                                                                                                                                                                                                    Page 2

DVBCWRM1  ;ALB/CMM RESPIRATORY, MISC. DISEASES WKS TEXT - 1 ; 6 MARCH 1997

 +1       ;;2.7;AMIE;**12**;Apr 10, 1995

 +2       ;

 +3       ;

TXT       ;

 +1       ;;A.  Review of Medical Records:

 +2       ;;

 +3       ;;

 +4       ;;

 +5       ;;B.  Medical History (Subjective Complaints):

 +6       ;;

 +7       ;;    Comment on:

 +8       ;;    1.  Fever and/or night sweats.

 +9       ;;

 +10      ;;

 +11      ;;    2.  Weight loss or gain.

 +12      ;;

 +13      ;;

 +14      ;;    3.  Daytime hypersomnolence.

 +15      ;;

 +16      ;;

 +17      ;;    4.  Hemoptysis.

 +18      ;;

 +19      ;;

 +20      ;;    5.  Describe current treatment such as anticoagulant, tracheostomy,

 +21      ;;        CPAP, oxygen, or antimicrobial therapy.

 +22      ;;

 +23      ;;

 +24      ;;    6.  If malignant disease, state initial treatment date, site of 

 +25      ;;        original tumor, type of tumor, types of treatment used, and 

 +26      ;;        date treatment is expected to end.  If treatment has been 

 +27      ;;        completed, state date treatment was completed.

 +28      ;;

 +29      ;;

 +30      ;;C.  Physical Examination (Objective Findings):

 +31      ;;

 +32      ;;    Address each of the following as appropriate to the condition 

 +33      ;;    being examined and fully describe current findings:

 +34      ;;    1.  Pulmonary Hypertension, RVH, cor pulmonale, or congestive 

 +35      ;;        heart failure.

 +36      ;;

 +37      ;;

 +38      ;;    2.  Residuals of pulmonary embolism.

 +39      ;;

 +40      ;;

 +41      ;;    3.  Respiratory Failure.

 +42      ;;

 +43      ;;

 +44      ;;    4.  Evidence of chronic pulmonary thromboembolism.

 +45      ;;

 +46      ;;

 +47      ;;    5.  If ankylosing spondylitis, is there restriction of the chest 

 +48      ;;        excursion and dyspnea on minimal exertion?

 +49      ;;

 +50      ;;

 +51      ;;    6.  Describe all residuals of malignancy including those due to 

 +52      ;;        treatment.

 +53      ;;

 +54      ;;

 +55      ;;D.  Diagnostic and Clinical Tests:

 +56      ;;

 +57      ;;    1.  Pulmonary Function Tests, if indicated. When the results of 

 +58      ;;        pre-bronchodilator pulmonary function tests are NORMAL, post-

 +59      ;;        bronchodilator studies are not required for VA evaluation 

 +60      ;;        purposes.  IN ALL OTHER CASES, post-bronchodilator studies 

 +61      ;;        should be conducted unless contraindicated (because of allergy

 +62      ;;        to medication, etc.) or if the veteran was on bronchodilators

 +63      ;;        before the test and had taken his or her medication within a 

 +64      ;;        few hours of the study.  An examiner who determines that a 

 +65      ;;        post-bronchodilator study should not be performed should 

 +66      ;;        provide an explanation of why not.  If there is a disparity 

 +67      ;;        between the results of different pulmonary function tests 

 +68      ;;        (FEV-1, FVC, etc.), the examiner should indicate which test 

 +69      ;;        result is the best indicator of the veteran's level of 

 +70      ;;        pulmonary functioning.

 +71      ;;    2.  If sleep apnea is suspected, order SLEEP STUDIES.

 +72      ;;    3.  Chest X-ray if necessary to document sarcoidosis or other 

 +73      ;;        parenchymal disease.

 +74      ;;    4.  Include results of all diagnostic and clinical tests conducted

 +75      ;;        in the examination report

 +76      ;;

 +77      ;;

 +78      ;;E.  Diagnosis:

 +79      ;;

 +80      ;;

 +81      ;;Signature:                             Date:

 +82      ;;END