source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRM1.m@ 628

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