source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCGMC1.m@ 628

DVBCGMC1 ;ALB ISC/THM-TEXT FOR GEN MED EXAM ; 5/21/91  9:47 AM
 ;;2.7;AMIE;;Apr 10, 1995
 ;
PTXT F AW=0:1 S AX=$T(@TXT+AW) S AY=$P(AX,";;",2) W:AY="END" !! Q:AY="END"  W AY,!
 Q
 ;
TXT2 ;;(describe type, area, extent of lesions and
 ;;   report injuries, including burns in the MUSCULOSKELETAL section of this
 ;;   form):
 ;;END
 ;
TXT3 ;;(describe local or generalized adenopathy,
 ;;   enlargement, tenderness, suppuration blocking of lymphatic circulation,
 ;;   etc..):
 ;;END
 ;
TXT4 ;;(describe findings on inspection and palpation,
 ;;   enlargements, masses, tenderness or rigidity, hemorrhoids (internal/external
 ;;   fissures, bowel movements - control or lack of):
 ;;END
 ;
TXT5 ;;(describe type, location, size, whether complete, reducible, recurrent,
 ;;   supported by truss or belt, and whether operable):
 ;;END
 ;
TXT6 ;;(describe kidneys, bladder, frequency
 ;;   of urination and control or lack thereof, prostate, seminal
 ;;   vesicles, testes, cord, penis, and appendages; evidence of
 ;;   past or present venereal disease; for females report pelvic
 ;;   exam, if indicated):
 ;;END
 ;
TXT7 ;;   1. Diseases and injuries (include effect of gunshot wounds and other
 ;;      injuries on skin and underlying structures) -
 ;;
 ;;
 ;;
 ;;
 ;;   2. Scars (describe location, measurements, depression, type oftissue
 ;;      loss adherence, disfiguration and tenderness) -
 ;;
 ;;
 ;;
 ;;
 ;;   3. Functional effects (describe location, swelling, atrophy, tenderness,
 ;;      degree of limitation of flexion and extension, angle of fixation, fracture
 ;;      or disease, fibrous or bony residual and specify mechanical aid used and
 ;;      benefit) -
 ;;
 ;;
 ;;
 ;;
 ;;   4. Feet (describe objective evidence of pain at rest and on manipulation,
 ;;      rigidity, spasm, circulatory disturbance, swelling, callus, strength,
 ;;      mobility of ankles, feet, toes and limitation in degrees and indicate
 ;;      whether right or left, acquired or congenital) -
 ;;
 ;;
 ;;
 ;;
 ;;   5. Burns (indicate degree, shape and dimension, specifying inches
 ;;      or centimeters)-
 ;;
 ;;
 ;;END
TXT8 ;;   1. Neurological (describe motor status, coordination, reflexes, sensory
 ;;      status equilibrium and give level of lesion) -
 ;;
 ;;
 ;;
 ;;
 ;;   2. Psychiatric and Personality (describe behavior, comprehension,
 ;;      coherence of response, emotional reaction, orientation, memory, signs
 ;;      of tension and response as to social and industrial capacity) -
 ;;
 ;;
 ;;
 ;;
 ;;
 ;;   3. State whether the veteran is capable of managing his/her benefit payments
 ;;      in the individual's own best interests without restriction (a physicial
 ;;      disability which prevents the veteran from attending to financial
 ;;      matters in person is not 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) -
 ;;
 ;;
 ;;
 ;;
 ;;END
 ;
TXT9 ;;(describe cough, expectoration, mobility, palpation,
 ;;   percussion, and auscultation and specify the area as well as
 ;;   the veteran's tolerance for exercise, such as how far can he
 ;;   walk, how many flights of stairs can he climb, etc.):
 ;;END
 ;
TXT10 ;;In many cases, this general examination will be the only examination conducted.
 ;;Accordingly, it is vital that all significant functional deficits should
 ;;be identified and described, including, but not limited to, the body systems
 ;;and parts involved in the history and present complaints.  If the examiner deems
 ;;that additional special studies and/or examinations are necessary for proper
 ;;diagnosis and/or evaluation, specific recommendations should be made.
 ;;
 ;;Negative results may be summarized as "negative" or "normal".
 ;;END