source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWHE1.m

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1DVBCWHE1 ;ALB/JFP HEART WKS TEXT - 1 ; 12 FEB 1998
2 ;;2.7;AMIE;**16**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;; Comment on:
10 ;; 1. Past history - describe onset of disorder and frequency of
11 ;; cardiac symptoms, including angina, dyspnea, fatigue,
12 ;; dizziness, and syncope. Record dates and severity of
13 ;; episodes of acute cardiac illness, including myocardial
14 ;; infarction, congestive heart failure, and acute rheumatic
15 ;; heart disease. Describe all cardiac surgery, including
16 ;; coronary artery bypass, valvular surgery, cardiac transplant,
17 ;; and angioplasty.
18 ;; 2. Current treatment - type, dosage, response, and side effects.
19 ;; 3. With the exceptions given below, examinations for valvular
20 ;; heart disease, endocarditis, pericarditis, pericardial
21 ;; adhesions, syphilitic heart disease, arteriosclerotic heart
22 ;; disease, myocardial infarction, hypertensive heart disease,
23 ;; heart valve replacement, coronary bypass sugery, cardiac
24 ;; transplanation, and cardiomyopathy, require the examiner to
25 ;; provide the METs level, determine by exercise testing, at
26 ;; which symptoms of dyspnea, fatigue, angina, dizziness, or
27 ;; syncope result.
28 ;; 4. Exercise testing is not required for the above listed
29 ;; conditions in the following circumstances:
30 ;; a. If exercise testing is medically contraindicated:
31 ;; 1) In that case, provide the medical reason exercise
32 ;; testing cannot be conducted, and
33 ;; 2) Provide an estimate of the level of activity
34 ;; (expressed in METs and supported by specific
35 ;; examples, such as slow stair climbing, or shoveling
36 ;; snow) that results in dyspnea, fatigue, angina,
37 ;; dizziness, or syncope.
38 ;; b. If left ventricular dysfunction is present, and the
39 ;; ejection fraction is 50 percent or less.
40 ;; c. If there is chronic congestive heart failure or there has
41 ;; been more than one episode of acute congestive heart
42 ;; failure in the past year.
43 ;; d. With valvular heart disease - during active infection
44 ;; with valvular heart damage and for three months following
45 ;; cessation of therapy for the active infection.
46 ;; e. With endocarditis - for three months following cessation
47 ;; of therapy for active infection with cardiac involvement.
48 ;; f. With pericarditis - for three months following cessation
49 ;; of therapy for active infection with cardiac involvement.
50 ;; g. With myocardial infarction - for three months following
51 ;; myocardial infarction.
52 ;; h. With valve replacement - for six months following date of
53 ;; hospital admission for valve replacement.
54 ;; i. With coronary bypass surgery - for three months following
55 ;; hospital admission for surgery.
56 ;; j. For cardiac transplantation - for indefinite period from
57 ;; date of hospital admission for cardiac transplantation.
58 ;; k. If an exercise test has been done within the past year,
59 ;; the results are of record, and there is no indication
60 ;; that there has been a change in the cardiac status of the
61 ;; veteran since.
62 ;; 5. For hyperthyroid heart disease, if atrial fibrillation is
63 ;; present, use arrhythmia worksheet. Also use endocrine
64 ;; worksheet if examining for hyperthyroidism.
65 ;; 6. Describe the effects of the condition on the veteran's usual
66 ;; occupation and daily activities.
67 ;; 7. Even when special examinations and tests (e.g., exercise
68 ;; testing) are not required under the worksheet guidelines, they
69 ;; may be requested or conducted at the discretion of the
70 ;; examiner, when the examiner believes that the available
71 ;; information does not fully reflect the severity of the
72 ;; veteran's cardiovascular disability.
73 ;;
74 ;;C. Physical Examination (Objective Findings):
75 ;; Address each of the following and fully describe current findings:
76 ;; 1. Heart size and method of determination, heart rhythm and rate,
77 ;; heart sounds, blood pressure.
78 ;; 2. Evidence of congestive heart failure - rales, edema, liver
79 ;; enlargement, etc.
80 ;;
81 ;;D. Diagnostic and Clinical Tests:
82 ;; 1. Chest X-ray, EKG, exercise stress test, echocardiogram,
83 ;; Holter monitor, thallium study, angiography, etc., as
84 ;; appropriate, and as required or indicated.
85 ;; 2. Include results of all diagnostic and clinical tests
86 ;; conducted in the examination report, including status of left
87 ;; ventricular function, if measured.
88 ;; 3. Valvular heart disease and endocarditis require documentation
89 ;; of diagnosis by physical findings and either echocardiogram,
90 ;; Doppler echocardiogram, or cardiac catheterization, if not
91 ;; already of record.
92 ;; 4. Other types of heart disease must be documented by appropriate
93 ;; objective diagnostic tests.
94 ;;
95 ;;E. Diagnosis and Opinion:
96 ;; 1. Type of heart disease and etiology, if known.
97 ;; 2. Type of surgery, if any, and results.
98 ;; 3. If the veteran is service-connected for rheumatic heart
99 ;; disease and later develops non-service-connected
100 ;; arteriosclerotic heart disease, state, if possible, which
101 ;; cardiac findings can be attributed to each condition. If it
102 ;; is not possible to separate the signs and symptoms of one
103 ;; from the other, so state, and explain.
104 ;;
105 ;;
106 ;;Signature: Date:
107 ;;END
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