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Routine: DVBCWRW1

DVBCWRW1.m

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  1. DVBCWRW1 ;ALB/CMM RESPIRATORY WKS TEXT - 1 ; 6 MARCH 1997
  1. ;;2.7;AMIE;**12**;Apr 10, 1995
  1. ;
  1. ;
  1. TXT ;
  1. ;;A. Review of Medical Records:
  1. ;;
  1. ;;
  1. ;;
  1. ;;B. Medical History (Subjective Complaints):
  1. ;;
  1. ;; Comment on:
  1. ;; 1. Productive cough, sputum, hemoptysis, and/or anorexia.
  1. ;;
  1. ;;
  1. ;; 2. Extent of dyspnea on exertion.
  1. ;;
  1. ;;
  1. ;; 3. If veteran is asthmatic, report frequency of attacks and
  1. ;; baseline functional status between attacks.
  1. ;;
  1. ;;
  1. ;; 4. Treatment (type, frequency and duration including a need for
  1. ;; oxygen), response, side effects.
  1. ;;
  1. ;;
  1. ;; 5. Describe frequency and duration of any periods of incapacitation
  1. ;; (defined as requiring bed rest and treatment by a physician).
  1. ;;
  1. ;;
  1. ;;C. Physical Examination (Objective Findings):
  1. ;;
  1. ;; Address each of the following as appropriate to the condition
  1. ;; being examined and fully describe current findings:
  1. ;; 1. Presence of cor pulmonale, RVH, or pulmonary hypertension.
  1. ;;
  1. ;;
  1. ;; 2. Weight loss or gain.
  1. ;;
  1. ;;
  1. ;; 3. For restrictive disease, describe condition underlying
  1. ;; restrictive disease, e.g., kyphoscoliosis, pectus excavatum,
  1. ;; etc., unless already of record.
  1. ;;
  1. ;;TOF
  1. ;;D. Diagnostic and Clinical Tests:
  1. ;;
  1. ;; Provide:
  1. ;; 1. PULMONARY FUNCTION TESTS (unless carried out within past six
  1. ;; months and the report is either in the claims folder or will
  1. ;; be attached to this examination report). When the results of
  1. ;; pre-bronchodilator pulmonary function tests are NORMAL, post-
  1. ;; bronchodilator studies are not required for VA evaluation
  1. ;; purposes. IN ALL OTHER CASES, post-bronchodilator studies
  1. ;; should be conducted unless contraindicated (because of allergy
  1. ;; to medication, etc.) or if the veteran was on bronchodilators
  1. ;; before the test and had taken his or her medication within a
  1. ;; few hours of the study. An examiner who determines that a
  1. ;; post-bronchodilator study should not be performed should
  1. ;; provide an explanation of why not. If there is a disparity
  1. ;; between the results of different pulmonary function tests
  1. ;; (FEV-1, FVC, etc.), the examiner should indicate which test
  1. ;; result is the best indicator of the veteran's level of
  1. ;; pulmonary functioning.
  1. ;; 2. Chest X-ray (if no recent results available).
  1. ;; 3. Include results of all diagnostic and clinical tests conducted
  1. ;; in the examination report.
  1. ;;
  1. ;;
  1. ;;E. Diagnosis:
  1. ;;
  1. ;;
  1. ;;Signature: Date:
  1. ;;END