source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGX2.m

DVBCWGX2 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**26**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;            4) If hypertension has not been claimed, take three blood
 ;;               pressure readings on the day of the examination.  If they
 ;;               are suggestive of hypertension or are borderline, readings
 ;;               MUST be taken two or more times on each of at least two
 ;;               additional days to rule hypertension in or out.
 ;;
 ;;
 ;;            5) In the diagnostic summary, state whether hypertension is
 ;;               ruled in or out after completing these B.P. measurements.
 ;;               Describe treatment for hypertension and side effects.  If
 ;;               hypertensive heart disease is suspected or found, follow
 ;;               worksheet for Heart.
 ;;
 ;;
 ;;   14.  ABDOMEN:  Inspection, auscultation, palpation, percussion.  
 ;;        Describe any organ enlargement, ventral hernia, mass,
 ;;        tenderness, etc.).  
 ;;
 ;;
 ;;   15.  GENITAL/RECTAL (MALE):  Inspection and palpation of penis, 
 ;;        testicles, epididymis, and spermatic cord.  If there is a hernia, 
 ;;        describe type, location, size, whether complete, reducible, 
 ;;        recurrent, supported by truss or belt, and whether or not 
 ;;        operable.  Describe anal fissures, hemorrhoids, ulcerations,
 ;;        etc.  Include digital exam of rectal walls and prostate.
 ;;
 ;;
 ;;   16.  GENITAL/RECTAL (FEMALE):  Pelvic exam, including inspection of
 ;;        introitus, vagina, and cervix, palpation of labia, vagina,
 ;;        cervix, uterus, adnexa, and ovaries, rectal exam.  Do Pap smear
 ;;        if none within past year.  If unable to conduct an examination
 ;;        and Pap smear, or if there is a severe or complex problem
 ;;        refer to a specialist to complete the examination.
 ;;
 ;;
 ;;   17.  MUSCULOSKELETAL:
 ;;        a. For all joint or muscle disorders, state each muscle and 
 ;;           joint affected.
 ;;
 ;;
 ;;        b. Separately examine and describe in detail each affected joint.
 ;;           Measure active and passive range of motion in degrees using a
 ;;           goniometer.  In addition, 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 musculoskeletal worksheet for more detail.)
 ;;           NOTE: The diagnosis of DEGENERATIVE OR TRAUMATIC ARTHRITIS OF
 ;;           ANY JOINT REQUIRES X-RAY CONFIRMATION, but once confirmed by
 ;;           X-ray, either in service or after service, no further X-rays
 ;;           of that joint are required for disability evaluation purposes.
 ;;
 ;;
 ;;        c. Describe swelling, effusion, tenderness, muscle spasm, joint
 ;;           laxity, muscle atrophy, fibrous or bony residual of fracture. If
 ;;           joint is ankylosed, describe the position and angle of fixation.
 ;;
 ;;
 ;;        d. Describe any mechanical aids used by veteran.
 ;;
 ;;
 ;;        e. If foot problems exit, also describe objective evidence of pain
 ;;           at rest and on manipulation, rigidity, spasm, circulatory
 ;;           disturbance, swelling, callus, loss of strength, and whether
 ;;           condition is acquired or congenital.
 ;;
 ;;
 ;;        f. If there is amputation of a part, see the appropriate worksheet.
 ;;
 ;;
 ;;        g. With disc disease, also describe any neurological findings.
 ;;
 ;;
 ;;
 ;;   18.  ENDOCRINE:  Describe signs and symptoms of any endocrine disease,
 ;;        effects on other body systems, and current and past treatment.
 ;;        See endocrine worksheets for further guidance.
 ;;
 ;;
 ;;   19.  NEUROLOGICAL:  Assess orientation and memory, gait, stance, and
 ;;        coordination, cranial nerve functions.  Assess deep tendon 
 ;;        reflexes, pain, touch, temperature, vibration, and position,
 ;;        motor and sensory status of peripheral nerves.  If neurological
 ;;        abnormalities are found on examination, or there is a history
 ;;        of seizures, refer to appropriate worksheet.
 ;;
 ;;
 ;;   20.  PSYCHIATRIC:  Describe behavior, comprehension, coherence of 
 ;;        response, emotional reaction, signs of tension and effects on
 ;;        social and occupational functioning.  (This is meant to be a
 ;;        brief screening examination.  If a mental disorder is CLAIMED,
 ;;        OR SUSPECTED BASED ON THE SCREENING, an examination for diagnosis
 ;;        and assessment should be conducted by a psychiatrist or
 ;;        psychologist).  State whether the veteran is capable of managing
 ;;        his or her benefit payments in his or her own best interests
 ;;        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.  Review all test results before providing the summary and diagnosis.
 ;;    3.  Follow additional worksheets, as appropriate.
 ;;
 ;;
 ;;
 ;;E.  DIAGNOSIS:  Provide a summary list of all disabilities diagnosed.
 ;;    Include an interpretation of the results of all diagnostic and other
 ;;    tests conducted in the final summary and diagnosis.  For each
 ;;    condition diagnosed, describe its effect on the veteran's usual 
 ;;    occupation and daily activities.
 ;;TOF
 ;;E.  DIAGNOSIS:  
 ;;
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END