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 ---[H[J[2J[HDVBCWRM1 2945 printed Apr 09, 2024@20:47:59 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
