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

DVBCWHE1 ;ALB/JFP HEART WKS TEXT - 1 ; 12 FEB 1998
 ;;2.7;AMIE;**16**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;    Comment on:
 ;;    1.  Past history - describe onset of disorder and frequency of
 ;;        cardiac symptoms, including angina, dyspnea, fatigue,
 ;;        dizziness, and syncope.  Record dates and severity of
 ;;        episodes of acute cardiac illness, including myocardial
 ;;        infarction, congestive heart failure, and acute rheumatic 
 ;;        heart disease.  Describe all cardiac surgery, including
 ;;        coronary artery bypass, valvular surgery, cardiac transplant,
 ;;        and angioplasty.
 ;;    2.  Current treatment - type, dosage, response, and side effects.
 ;;    3.  With the exceptions given below, examinations for valvular
 ;;        heart disease, endocarditis, pericarditis, pericardial
 ;;        adhesions, syphilitic heart disease, arteriosclerotic heart
 ;;        disease, myocardial infarction, hypertensive heart disease,
 ;;        heart valve replacement, coronary bypass sugery, cardiac
 ;;        transplanation, and cardiomyopathy, require the examiner to
 ;;        provide the METs level, determine by exercise testing, at
 ;;        which symptoms of dyspnea, fatigue, angina, dizziness, or
 ;;        syncope result. 
 ;;    4.  Exercise testing is not required for the above listed
 ;;        conditions in the following circumstances:
 ;;          a. If exercise testing is medically contraindicated:
 ;;             1)  In that case, provide the medical reason exercise
 ;;                 testing cannot be conducted, and
 ;;             2)  Provide an estimate of the level of activity
 ;;                 (expressed in METs and supported by specific
 ;;                 examples, such as slow stair climbing, or shoveling
 ;;                 snow) that results in dyspnea, fatigue, angina,
 ;;                 dizziness, or syncope.
 ;;          b. If left ventricular dysfunction is present, and the
 ;;             ejection fraction is 50 percent or less.
 ;;          c. If there is chronic congestive heart failure or there has
 ;;             been more than one episode of acute congestive heart
 ;;             failure in the past year.
 ;;          d. With valvular heart disease - during active infection
 ;;             with valvular heart damage and for three months following
 ;;             cessation of therapy for the active infection.
 ;;          e. With endocarditis - for three months following cessation
 ;;             of therapy for active infection with cardiac involvement.
 ;;          f. With pericarditis - for three months following cessation
 ;;             of therapy for active infection with cardiac involvement.
 ;;          g. With myocardial infarction - for three months following
 ;;             myocardial infarction.
 ;;          h. With valve replacement - for six months following date of
 ;;             hospital admission for valve replacement.
 ;;          i. With coronary bypass surgery - for three months following
 ;;             hospital admission for surgery.
 ;;          j. For cardiac transplantation - for indefinite period from
 ;;             date of hospital admission for cardiac transplantation.
 ;;          k. If an exercise test has been done within the past year,
 ;;             the results are of record, and there is no indication
 ;;             that there has been a change in the cardiac status of the
 ;;             veteran since.
 ;;    5.  For hyperthyroid heart disease, if atrial fibrillation is
 ;;        present, use arrhythmia worksheet.  Also use endocrine
 ;;        worksheet if examining for hyperthyroidism.
 ;;    6.  Describe the effects of the condition on the veteran's usual
 ;;        occupation and daily activities.
 ;;    7.  Even when special examinations and tests (e.g., exercise
 ;;        testing) are not required under the worksheet guidelines, they
 ;;        may be requested or conducted at the discretion of the
 ;;        examiner, when the examiner believes that the available
 ;;        information does not fully reflect the severity of the
 ;;        veteran's cardiovascular disability.
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Heart size and method of determination, heart rhythm and rate,
 ;;        heart sounds, blood pressure.
 ;;    2.  Evidence of congestive heart failure - rales, edema, liver
 ;;        enlargement, etc.
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;    1.  Chest X-ray, EKG, exercise stress test, echocardiogram,
 ;;        Holter monitor, thallium study, angiography, etc., as
 ;;        appropriate, and as required or indicated.
 ;;    2.  Include results of all diagnostic and clinical tests
 ;;        conducted in the examination report, including status of left
 ;;        ventricular function, if measured.
 ;;    3.  Valvular heart disease and endocarditis require documentation
 ;;        of diagnosis by physical findings and either echocardiogram,
 ;;        Doppler echocardiogram, or cardiac catheterization, if not
 ;;        already of record.  
 ;;    4.  Other types of heart disease must be documented by appropriate
 ;;        objective diagnostic tests.
 ;;
 ;;E.  Diagnosis and Opinion:
 ;;    1.  Type of heart disease and etiology, if known.
 ;;    2.  Type of surgery, if any, and results.
 ;;    3.  If the veteran is service-connected for rheumatic heart
 ;;        disease and later develops non-service-connected
 ;;        arteriosclerotic heart disease, state, if possible, which
 ;;        cardiac findings can be attributed to each condition.  If it
 ;;        is not possible to separate the signs and symptoms of one
 ;;        from the other, so state, and explain.
 ;;
 ;;
 ;;Signature:                                        Date:
 ;;END