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