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1DVBCWGM1 ;ALB/CMM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;Narrative: This is a complete, base-line examination covering all
7 ;;parts of the body, not just the areas claimed by the veteran. The
8 ;;examiner may request any additional studies or examinations as needed
9 ;;for proper diagnosis and evaluation. All important negatives should
10 ;;be reported. If a diagnosis is uncovered that was not originally
11 ;;claimed by the veteran, complete the appropriate worksheet, in
12 ;;addition to this one. A general medical examination may also be
13 ;;requested as evidence for non service-connected disability pension
14 ;;claims or for claimed entitlement to individual unemployability
15 ;;benefits in service-connected disability compensation claims.
16 ;;
17 ;;A. REVIEW OF MEDICAL RECORDS;
18 ;;
19 ;;
20 ;;
21 ;;B. MEDICAL HISTORY (Subjective Complaints):
22 ;;
23 ;; Comment on:
24 ;; 1. If the injury or disease OCCURRED IN THE MILITARY:
25 ;; a. Completely describe the circumstances, injury, treatment,
26 ;; follow-up, and residuals in the military.
27 ;;
28 ;;
29 ;; b. Completely describe the circumstances, injury, treatment,
30 ;; follow-up, and residuals after the military.
31 ;;
32 ;;
33 ;; 2. If the injury or disease OCCURRED BEFORE THE MILITARY:
34 ;; a. Completely describe the circumstances, injury, treatment,
35 ;; follow-up, and residuals before entering the military.
36 ;;
37 ;;
38 ;; b. Completely describe any worsening of residuals due to being
39 ;; in the military.
40 ;;
41 ;;
42 ;; c. Completely describe the circumstances, injury, treatment,
43 ;; follow-up, and residuals after the military.
44 ;;
45 ;;
46 ;; 3. If the injury or disease OCCURRED AFTER THE MILITARY:
47 ;; a. Completely describe the circumstances, injury, treatment,
48 ;; follow-up, and residuals after the military.
49 ;;
50 ;;
51 ;; 4. Occupational history:
52 ;; a. Obtain the name and address of the employer (list most
53 ;; current first), type of occupation, employment dates,
54 ;; wages for last 12 months. If any time was lost from work,
55 ;; please describe the reason and extent of time lost.
56 ;;
57 ;;
58 ;;C. PHYSICAL EXAMINATION (Objective Findings):
59 ;;
60 ;; Address each of the following and fully describe current findings:
61 ;; The examiner should incorporate all ancillary study results into
62 ;; the final diagnoses.
63 ;;
64 ;; 1. VS: Heart rate, blood pressure (If the diagnosis of hypertension
65 ;; has not been established, take 2 or more blood pressure readings
66 ;; on at least 3 different days. If hypertension has been
67 ;; diagnosed, take 2 or more blood pressure readings.), respirations,
68 ;; height, weight, maximum weight in past year, weight change in
69 ;; past year, body build, and state of nutrition.
70 ;;
71 ;;
72 ;; 2. DOMINANT HAND: Indicate the dominant hand and how determined
73 ;; (i.e., writes, eats, combs hair, etc.).
74 ;;
75 ;;
76 ;; 3. POSTURE AND GAIT: (If abnormal, describe.)
77 ;;
78 ;;
79 ;; 4. SKIN, INCLUDING APPENDAGES: (If abnormal, describe appearance,
80 ;; location, extent of lesions and limitations to daily activity.)
81 ;; If there are laceration or burn scars, describe the location,
82 ;; measurements (cm. x cm.), shape, depression, type of tissue
83 ;; loss, adherence, disfigurement and tenderness. For each burn
84 ;; scar, state if due to a 2nd or 3rd degree burn. (NOTE: If
85 ;; the skin condition or scars are disfiguring, obtain COLOR
86 ;; PHOTOGRAPHS of affected area(s).
87 ;;
88 ;;
89 ;; 5. HEMIC AND LYMPHATIC: (Describe local or generalized adenopathy,
90 ;; tenderness, suppuration, etc.)
91 ;;
92 ;;
93 ;; 6. HEAD AND FACE: Describe scars, deformities, etc.
94 ;;
95 ;;
96 ;; 7. EYES: Describe external eye, pupil reaction, movements, field
97 ;; of vision,any uncorrectable refractive error, or any retinopathy.
98 ;;
99 ;;
100 ;; 8. EARS: Describe canals, drums, perforations, discharge.
101 ;;
102 ;;
103 ;; 9. NOSE, SINUSES, MOUTH AND THROAT: Include gross dental findings.
104 ;;
105 ;;
106 ;; 10. NECK: Describe lymph nodes, thyroid, etc.
107 ;;
108 ;;
109 ;; 11. CHEST: Inspection, palpation, percussion, auscultation. If
110 ;; abnormal, describe limitations of daily living (i.e., How far
111 ;; can veteran walk, how many flights of stairs can he or she
112 ;; climb, etc.).
113 ;;
114 ;;
115 ;; 12. BREAST: Comment on any masses palpated in breast parenchyma
116 ;; including axillary tail. Comment on any skin abnormalities.
117 ;; Comment on any discharge from nipples.
118 ;;
119 ;;
120 ;; 13. CARDIOVASCULAR: Record pulse, heart sounds, abnormalities
121 ;; (i.e., arrhythmias, murmurs, etc.), and status of peripheral
122 ;; vessels. Note edema. Describe varicose veins including
123 ;; location, size, extent, ulcers, scars, and competency of deep
124 ;; circulation. Examine for evidence of residuals of frostbite
125 ;; when indicated. See Cold Injuries Examination Worksheet.
126 ;; (NOTE: Cardiovascular signs and symptoms should be graded
127 ;; using NYHA scale.)
128 ;;
129 ;;
130 ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
131 ;; If abnormal, describe (i.e., abdominal enlargement, masses,
132 ;; tenderness, etc.).
133 ;;
134 ;;
135 ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
136 ;; testicles, epididymis, and spermatic cord. (If hernia,
137 ;; describe type, location, size, whether complete, reducible,
138 ;; recurrent, supported by truss or belt, and whether or not
139 ;; operable). Inspection of anus for fissures, hemorrhoids,
140 ;; ulcerations, etc., and digital exam of rectal walls, and prostate.
141 ;;
142 ;;
143 ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam should include inspection
144 ;; of introitus, vagina, and cervix, palpation of labia, vagina,
145 ;; cervix, uterus, adnexa, and ovaries. Pap smear (if none within
146 ;; past year). Inspection of anus for fissures, hemorrhoids,
147 ;; ulcerations, etc., and digital exam of rectal walls. Any
148 ;; severe abnormalities may be referred to a specialist.
149 ;;
150 ;;
151 ;; 17. MUSCULOSKELETAL: For joint or muscle defects, describe
152 ;; location, swelling, atrophy, tenderness, active and passive
153 ;; motion in degrees using a goniometer, angle of fixation,
154 ;; fracture, fibrous or bony residual, and mechanical aids used
155 ;; by veteran. Provide an assessment of the effect on range of
156 ;; motion and joint function of pain, weakness, fatigue, or
157 ;; incoordination following repetitive use or during flare-ups.
158 ;; (See the appropriate worksheet for more detail.) If foot
159 ;; problems exist, perform above exam and also include objective
160 ;; evidence of pain at rest and on manipulation, rigidity, spasm,
161 ;; circulatory disturbance, swelling, callus, loss of strength,
162 ;; mobility of ankles an feet, and whether acquired or congenital.
163 ;;
164 ;;
165 ;; 18. ENDOCRINE: Describe disease of thyroid, pituitary, adrenals,
166 ;; gonads, other body systems affected, etc.
167 ;;
168 ;;
169 ;; 19. NEUROLOGICAL: Cerebrum - orientation and memory. Cerebellum
170 ;; - gait, stance, coordination. Spinal Cord - deep tendon
171 ;; reflexes, pain, touch, temperature, vibration, position.
172 ;; Cranial nerves - I-XII. If abnormalities are found, describe
173 ;; region of CNS affected.
174 ;;
175 ;;
176 ;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
177 ;; response, emotional reaction, signs of tension, and response
178 ;; to social and occupational environment. State whether the
179 ;; veteran is capable of managing his or her benefit payments in
180 ;; his or her own best interest without restriction. (A physical
181 ;; disability which prevents the veteran from attending to
182 ;; financial matters in person is not a proper basis for a
183 ;; finding of incompetency unless the veteran is, by reason of
184 ;; that disability, incapable of directing someone else in
185 ;; handling the individual's financial affairs.)
186 ;;
187 ;;
188 ;;D. DIAGNOSTIC AND CLINICAL TESTS:
189 ;;
190 ;; 1. Include results of all diagnostic and clinical tests conducted
191 ;; in the examination report.
192 ;; 2. All test results must be reviewed prior to final summary and
193 ;; diagnosis.
194 ;;
195 ;;TOF
196 ;;E. DIAGNOSIS:
197 ;;
198 ;;
199 ;;
200 ;;Signature: Date:
201 ;;END
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