source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGM1.m

DVBCWGM1 ;ALB/CMM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;Narrative:  This is a complete, base-line examination covering all 
 ;;parts of the body, not just the areas claimed by the veteran.  The 
 ;;examiner may request any additional studies or examinations as needed
 ;;for proper diagnosis and evaluation.  All important negatives should 
 ;;be reported.  If a diagnosis is uncovered that was not originally 
 ;;claimed by the veteran, complete the appropriate worksheet, in 
 ;;addition to this one.  A general medical examination may also be 
 ;;requested as evidence for non service-connected disability pension 
 ;;claims or for claimed entitlement to individual unemployability 
 ;;benefits in service-connected disability compensation claims.
 ;;
 ;;A.  REVIEW OF MEDICAL RECORDS;
 ;;
 ;;
 ;;
 ;;B.  MEDICAL HISTORY (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  If the injury or disease OCCURRED IN THE MILITARY:
 ;;        a.  Completely describe the circumstances, injury, treatment,
 ;;            follow-up, and residuals in the military.
 ;;
 ;;
 ;;        b.  Completely describe the circumstances, injury, treatment,
 ;;            follow-up, and residuals after the military.
 ;;
 ;;
 ;;    2.  If the injury or disease OCCURRED BEFORE THE MILITARY:
 ;;        a. Completely describe the circumstances, injury, treatment, 
 ;;           follow-up, and residuals before entering the military.
 ;;
 ;;
 ;;        b. Completely describe any worsening of residuals due to being
 ;;           in the military.
 ;;
 ;;
 ;;        c. Completely describe the circumstances, injury, treatment, 
 ;;           follow-up, and residuals after the military.
 ;;
 ;;
 ;;    3.  If the injury or disease OCCURRED AFTER THE MILITARY:
 ;;        a.  Completely describe the circumstances, injury, treatment,
 ;;            follow-up, and residuals after the military.
 ;;
 ;;
 ;;    4.  Occupational history:
 ;;        a.  Obtain the name and address of the employer (list most 
 ;;            current first), type of occupation, employment dates, 
 ;;            wages for last 12 months.  If any time was lost from work,
 ;;            please describe the reason and extent of time lost.
 ;;
 ;;
 ;;C.  PHYSICAL EXAMINATION (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    The examiner should incorporate all ancillary study results into 
 ;;    the final diagnoses.
 ;;
 ;;    1.  VS:  Heart rate, blood pressure (If the diagnosis of hypertension 
 ;;        has not been established, take 2 or more blood pressure readings 
 ;;        on at least 3 different days.  If hypertension has been 
 ;;        diagnosed, take 2 or more blood pressure readings.), respirations, 
 ;;        height, weight, maximum weight in past year, weight change in
 ;;        past year, body build, and state of nutrition.
 ;;
 ;;
 ;;    2.  DOMINANT HAND:  Indicate the dominant hand and how determined
 ;;        (i.e., writes, eats, combs hair, etc.).
 ;;
 ;;
 ;;    3.  POSTURE AND GAIT:  (If abnormal, describe.)
 ;;
 ;;
 ;;    4.  SKIN, INCLUDING APPENDAGES:  (If abnormal, describe appearance, 
 ;;        location, extent of lesions and limitations to daily activity.)  
 ;;        If there are laceration or burn scars, describe the location,
 ;;        measurements (cm. x cm.), shape, depression, type of tissue 
 ;;        loss, adherence, disfigurement and tenderness.  For each burn
 ;;        scar, state if due to a 2nd or 3rd degree burn.  (NOTE:  If 
 ;;        the skin condition or scars are disfiguring, obtain COLOR 
 ;;        PHOTOGRAPHS of affected area(s).
 ;;
 ;;
 ;;    5.  HEMIC AND LYMPHATIC:  (Describe local or generalized adenopathy, 
 ;;        tenderness, suppuration, etc.)
 ;;
 ;;
 ;;    6.  HEAD AND FACE:  Describe scars, deformities, etc.
 ;;
 ;;
 ;;    7.  EYES:  Describe external eye, pupil reaction, movements, field
 ;;        of vision,any uncorrectable refractive error, or any retinopathy.
 ;;
 ;;
 ;;    8.  EARS:  Describe canals, drums, perforations, discharge.
 ;;
 ;;
 ;;    9.  NOSE, SINUSES, MOUTH AND THROAT:  Include gross dental findings.
 ;;
 ;;
 ;;   10.  NECK:  Describe lymph nodes, thyroid, etc.
 ;;
 ;;
 ;;   11.  CHEST:  Inspection, palpation, percussion, auscultation.  If 
 ;;        abnormal, describe limitations of daily living (i.e., How far
 ;;        can veteran walk, how many flights of stairs can he or she 
 ;;        climb, etc.).
 ;;
 ;;
 ;;   12.  BREAST:  Comment on any masses palpated in breast parenchyma 
 ;;        including axillary tail.  Comment on any skin abnormalities. 
 ;;        Comment on any discharge from nipples.
 ;;
 ;;
 ;;   13.  CARDIOVASCULAR:  Record pulse, heart sounds, abnormalities 
 ;;        (i.e., arrhythmias, murmurs, etc.), and status of peripheral 
 ;;        vessels.  Note edema.  Describe varicose veins including 
 ;;        location, size, extent, ulcers, scars, and competency of deep
 ;;        circulation.  Examine for evidence of residuals of frostbite 
 ;;        when indicated.  See Cold Injuries Examination Worksheet.   
 ;;        (NOTE:  Cardiovascular signs and symptoms should be graded 
 ;;        using NYHA scale.)
 ;;
 ;;
 ;;   14.  ABDOMEN:  Inspection, auscultation, palpation, percussion.  
 ;;        If abnormal, describe (i.e., abdominal enlargement, masses, 
 ;;        tenderness, etc.).  
 ;;
 ;;
 ;;   15.  GENITAL/RECTAL (MALE):  Inspection and palpation of penis, 
 ;;        testicles, epididymis, and spermatic cord.  (If hernia, 
 ;;        describe type, location, size, whether complete, reducible, 
 ;;        recurrent, supported by truss or belt, and whether or not 
 ;;        operable).  Inspection of anus for fissures, hemorrhoids, 
 ;;        ulcerations, etc., and digital exam of rectal walls, and prostate.
 ;;
 ;;
 ;;   16.  GENITAL/RECTAL (FEMALE):  Pelvic exam should include inspection 
 ;;        of introitus, vagina, and cervix, palpation of labia, vagina,
 ;;        cervix, uterus, adnexa, and ovaries.  Pap smear (if none within 
 ;;        past year).  Inspection of anus for fissures, hemorrhoids, 
 ;;        ulcerations, etc., and digital exam of rectal walls.  Any 
 ;;        severe abnormalities may be referred to a specialist.
 ;;
 ;;
 ;;   17.  MUSCULOSKELETAL:  For joint or muscle defects, describe 
 ;;        location, swelling, atrophy, tenderness, active and passive 
 ;;        motion in degrees using a goniometer, angle of fixation, 
 ;;        fracture, fibrous or bony residual, and mechanical aids used 
 ;;        by veteran.  Provide an assessment of the effect on range of 
 ;;        motion and joint function of pain, weakness, fatigue, or 
 ;;        incoordination following repetitive use or during flare-ups.  
 ;;        (See the appropriate worksheet for more detail.)  If foot 
 ;;        problems exist, perform above exam and also include objective
 ;;        evidence of pain at rest and on manipulation, rigidity, spasm,
 ;;        circulatory disturbance, swelling, callus, loss of strength, 
 ;;        mobility of ankles an feet, and whether acquired or congenital.
 ;;
 ;;
 ;;   18.  ENDOCRINE:  Describe disease of thyroid, pituitary, adrenals,
 ;;        gonads, other body systems affected, etc.
 ;;
 ;;
 ;;   19.  NEUROLOGICAL:  Cerebrum - orientation and memory.  Cerebellum
 ;;        - gait, stance, coordination.  Spinal Cord - deep tendon 
 ;;        reflexes, pain, touch, temperature, vibration, position.  
 ;;        Cranial nerves - I-XII.  If abnormalities are found, describe
 ;;        region of CNS affected.  
 ;;
 ;;
 ;;   20.  PSYCHIATRIC:  Describe behavior, comprehension, coherence of 
 ;;        response, emotional reaction, signs of tension, and response 
 ;;        to social and occupational environment.  State whether the 
 ;;        veteran is capable of managing his or her benefit payments in
 ;;        his or her own best interest without restriction.  (A physical
 ;;        disability which prevents the veteran from attending to 
 ;;        financial matters in person is not a 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.)
 ;;
 ;;
 ;;D.  DIAGNOSTIC AND CLINICAL TESTS:
 ;;
 ;;    1.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;    2.  All test results must be reviewed prior to final summary and 
 ;;        diagnosis.
 ;;
 ;;TOF
 ;;E.  DIAGNOSIS:  
 ;;
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END