source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGX1.m

DVBCWGX1 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**26**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;NARRATIVE:  This is a comprehensive base-line or screening examination for 
 ;;all body systems, not just specific conditions claimed by the veteran.
 ;;It is often the initial post-discharge examination of a veteran requested
 ;;by the Compensation and Pension Service for disability compensation
 ;;purposes.  As a screening examination, it is not meant to elicit the
 ;;detailed information about specific conditions that is necessary for rating
 ;;purposes.  Therefore, all claimed conditions, and any found or suspected
 ;;conditions that were not claimed, should be addressed by referring to
 ;;and following all appropriate worksheets, in addition to this one, to 
 ;;assure that the examination for each condition provides information
 ;;adequate for rating purposes.  This does not require that a medical
 ;;specialist conduct examinations based on other worksheets, except in the
 ;;case of vision and hearing problems, mental disorders, or especially
 ;;complex or unusual problems.  VISION, HEARING, AND MENTAL DISORDER
 ;;EXAMINATIONS MUST BE CONDUCTED BY A SPECIALIST.  The examiner may request
 ;;any additional studies or examinations needed for proper diagnosis and
 ;;evaluation (see other worksheets for guidance).  All important negatives
 ;;should be reported.  The regional office may also request a general medical
 ;;examination as evidence for nonservice-connected disability pension claims
 ;;or for claimed entitlement to individual unemployability benefits in
 ;;service-connected disability compensation claims.  Barring unusual
 ;;problems, examinations for pension should generally be adequate if only
 ;;this general worksheet is followed.
 ;;
 ;;
 ;;A.  REVIEW OF MEDICAL RECORDS:  Indicate whether the C-file was reviewed.
 ;;
 ;;
 ;;
 ;;B.  MEDICAL HISTORY (Subjective Complaints):
 ;;
 ;;    1.  Discuss:  Whether an injury or disease that is found OCCURRED 
 ;;        DURING ACTIVE SERVICE, BEFORE ACTIVE SERVICE, OR AFTER ACTIVE 
 ;;        SERVICE.  To the extent possible, describe the circumstances,
 ;;        dates, specific injury or disease that occurred, treatment,
 ;;        follow-up, and residuals.  If the injury or disease occurred
 ;;        BEFORE ACTIVE SERVICE, describe any worsening of residuals due
 ;;        to being in military service.  Describe current symptoms and
 ;;        treatment.
 ;;
 ;;
 ;;    2.  Occupational history (for PENSION and INDIVIDUAL UMEMPLOYABILITY
 ;;        claims):  Obtain the name and address of employers (list most
 ;;        current first), type of occupation, employment dates, and wages
 ;;        for last 12 months.  If any time was lost from work in the past
 ;;        12-month period, please describe the reason and the extent of 
 ;;        time lost.
 ;;
 ;;
 ;;    3.  Describe details of current treatment, conditions being treated,
 ;;        and side effects of treatment.
 ;;
 ;;
 ;;    4.  Describe all surgery and hospitalizations in and after service
 ;;        with approximate dates.
 ;;
 ;;
 ;;    5.  If a malignant neoplasm is or was present, provide:
 ;;        a.  Date of confirmed diagnosis.
 ;;
 ;;
 ;;        b.  Date of the last surgical, X-ray, antineoplastic chemotherapy,
 ;;            radiation, or other therapeutic procedure.
 ;;
 ;;
 ;;        c.  State expected date treatment regimen is to be completed.
 ;;
 ;;
 ;;        d.  If treatment is already completed, provide date of last treatment.
 ;;
 ;;
 ;;        e.  If treatment is already completed, fully describe residuals.
 ;;
 ;;
 ;;
 ;;C.  PHYSICAL EXAMINATION (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    The examiner should incorporate results of all ancillary studies
 ;;    into the final diagnoses.
 ;;
 ;;    1.  VS:  Heart rate, blood pressure (see #13 below), 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 this was
 ;;        determined, e.g., writes, eats, combs hair with that hand.
 ;;
 ;;
 ;;    3.  POSTURE AND GAIT:  Describe abnormality and reason for it.
 ;;        Describe any ambulatory aids.
 ;;
 ;;
 ;;    4.  SKIN, INCLUDING APPENDAGES:  If abnormal, describe appearance, 
 ;;        location, extent of lesions.  If there are laceration or burn
 ;;        scars, describe the location, exact measurements (cm. x cm.),
 ;;        shape, depression, type of tissue loss, adherence, and tenderness.
 ;;        For each burn scar, state if due to a 2nd or 3rd degree burn.
 ;;        Describe any limitation of activity or limitation of motion
 ;;        due to scarring or other skin lesions.
 ;;        NOTE:  If there are disfiguring scars (of face, head, or neck),
 ;;               obtain COLOR PHOTOGRAPHS of the affected area(s) to submit
 ;;               with the examination report.
 ;;
 ;;
 ;;    5.  HEMIC AND LYMPHATIC:  Describe adenopathy, tenderness,
 ;;        suppuration, edema, pallor, etc.
 ;;
 ;;
 ;;    6.  HEAD AND FACE:  Describe scars, skin lesions, deformities, etc.,
 ;;        as discussed under item #4.
 ;;
 ;;
 ;;    7.  EYES:  Describe external eye, pupil reaction, eye movements.
 ;;
 ;;
 ;;    8.  EARS:  Describe canals, drums, perforations, discharge.
 ;;
 ;;
 ;;    9.  NOSE, SINUSES, MOUTH AND THROAT:  Include gross dental findings.
 ;;        For sinusitis, describe headaches, pain, episodes of 
 ;;        incapacitation, frequency and duration of antibiotic treatment.
 ;;
 ;;
 ;;   10.  NECK:  Describe lymph nodes, thyroid, etc.
 ;;
 ;;
 ;;   11.  CHEST:  Inspection, palpation, percussion, auscultation.  Describe
 ;;        respiratory symptoms and effect on daily activities, e.g., how
 ;;        far the veteran can walk, how many flights of stairs veteran 
 ;;        can climb.  If a respiratory condition is claimed or suspected,
 ;;        refer to appropriate worksheet(s).  Most respiratory conditions
 ;;        will require PFT's, including post-bronchodilation studies.
 ;;        Describe in detail any treatment for pulmonary disease.
 ;;
 ;;
 ;;   12.  BREAST:  Describe masses, scars, nipple discharge, skin
 ;;        abnormalities.  Give date of last mammogram, if any.  Describe
 ;;        any breast surgery (with approximate date) and residuals.
 ;;
 ;;
 ;;   13.  CARDIOVASCULAR:  NOTE: If there is evidence of a cardiovascular
 ;;        disease, or one is claimed, refer to appropriate worksheet(s).
 ;;
 ;;        a.  Record pulse, quality of heart sounds, abnormal heart sounds,
 ;;            arrhythmias.  Describe symptoms and treatment for any 
 ;;            cardiovascular conditions, including peripheral arterial
 ;;            and venous disease.  Give NYHA classification of heart disease. 
 ;;            A determination of METS by exercise testing may be required
 ;;            for certain cardiovascular conditions, and an estimation of
 ;;            METS may be required if exercise testing cannot be conducted
 ;;            for medical reasons.  (See the cardiovascular worksheet
 ;;            for further guidance.)
 ;;
 ;;
 ;;        b.  Describe the status of peripheral vessels and pulses.
 ;;            Describe edema, stasis pigmentation or eczema, ulcers, or
 ;;            other skin or nail abnormalities.  Describe varicose veins,
 ;;            including extent to which any resulting edema is relieved
 ;;            by elevation of extremity.  Examine for evidence of residuals
 ;;            of cold injury when indicated.  See and follow special cold
 ;;            injury examination worksheet if there is a history of cold
 ;;            exposure in service and the special cold injury examination
 ;;            has not been previously done.
 ;;
 ;;
 ;;        c.  BLOOD PRESSURE:  (Per the rating schedule, hypertension means
 ;;            that the diastolic blood pressure is predominantly 90 mm.
 ;;            or greater, and isolated systolic hypertension means that
 ;;            the systolic blood pressure is predominantly 160 mm. or
 ;;            greater with a diastolic blood pressure of less than 90 mm.)
 ;;
 ;;            1) If the diagnosis of hypertension has not been previously
 ;;               established, and it is a claimed issue, B.P. readings
 ;;               MUST be taken two or more times on each of at least 
 ;;               three different days.
 ;;
 ;;
 ;;            2) If hypertension has been previously diagnosed and is
 ;;               claimed, but the claimant is not on treatment, B.P. 
 ;;               readings MUST be taken two or more times on each of
 ;;               at least three different days.
 ;;
 ;;
 ;;            3) If hypertension has been previously diagnosed, and the
 ;;               claimant is on treatment, take three blood pressure 
 ;;               readings on the day of the examination.
 ;;TOF