source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWP2.m@ 1397

DVBCWP2 ;ALB/CMM POW, GENERAL WKS TEXT - 2 ; 7 MARCH 1997
 ;;2.7;AMIE;**12,56**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;   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.  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 and 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 capacity.  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.  As indicated - e.g., parasite studies, X-rays of joints, etc.
 ;;    2.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;1.  Complete, review and comment on all laboratory and diagnostic tests. 
 ;;
 ;;2.  Provide diagnoses.
 ;;
 ;;3.  Where some evidence indicates the disability may not have been 
 ;;    incurred in service, please provide an opinion as to whether
 ;;    the disease or injury was at least as likely as not incurred
 ;;    in service. Please base your opinion on sound medical reasoning
 ;;    and complete consideration of all the evidence of record.
 ;;    Please discuss your reasoning and the evidence you considered in
 ;;    formulating your opinion.
 ;;
 ;;
 ;;Signature:                             Date:
 ;;
 ;;___________________________________________________________
 ;;END