source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWPA2.m@ 1607

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1DVBCWPA2 ;ALB/CMM POW, GENERAL WKS TEXT - 2 ; 7 MARCH 1997
2 ;;2.7;AMIE;**79**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;; 12. BREAST: Comment on any masses palpated in breast parenchyma
7 ;; including axillary tail. Comment on any skin abnormalities.
8 ;; Comment on any discharge from nipples.
9 ;;
10 ;;
11 ;; 13. CARDIOVASCULAR: Record pulse, heart sounds, abnormalities
12 ;; (i.e., arrhythmias, murmurs, etc.), and status of peripheral
13 ;; vessels. Note edema. Describe varicose veins including
14 ;; location, size, extent, ulcers, scars, and competency of deep
15 ;; circulation. Examine for evidence of residuals of frostbite
16 ;; when indicated. See cold injuries examination worksheet.
17 ;; (NOTE: Cardiovascular signs and symptoms should be graded
18 ;; using NYHA scale.)
19 ;;
20 ;;
21 ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion. If
22 ;; abnormal, describe (i.e., abdominal enlargement, masses,
23 ;; tenderness, etc.).
24 ;;
25 ;;
26 ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
27 ;; testicles, epididymis, and spermatic cord. (If hernia,
28 ;; describe type, location, size, whether complete, reducible,
29 ;; recurrent, supported by truss or belt, and whether or not
30 ;; operable). Inspection of anus for fissures, hemorrhoids,
31 ;; ulcerations, etc., and digital exam of rectal walls, and
32 ;; prostate.
33 ;;
34 ;;
35 ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam should include inspection
36 ;; of introitus, vagina, and cervix, palpation of labia, vagina,
37 ;; cervix, uterus, adnexa, and ovaries. Inspection of anus for
38 ;; fissures, hemorrhoids, ulcerations, etc., and digital exam of
39 ;; rectal walls. Any severe abnormalities may be referred to a
40 ;; specialist.
41 ;;
42 ;;
43 ;; 17. MUSCULOSKELETAL: For joint or muscle defects, describe location,
44 ;; swelling, atrophy, tenderness, active and passive motion in
45 ;; degrees using a goniometer, angle of fixation, fracture,
46 ;; fibrous or bony residual, and mechanical aids used by veteran.
47 ;; Provide an assessment of the effect on range of motion and
48 ;; joint function of pain, weakness, fatigue, or incoordination
49 ;; following repetitive use or during flare-ups. (See the
50 ;; appropriate worksheet for more detail.) If foot problems
51 ;; exist, perform above exam and also include objective evidence
52 ;; of pain at rest and on manipulation, rigidity, spasm,
53 ;; circulatory disturbance, swelling, callus, loss of strength,
54 ;; mobility of ankles and feet, and whether acquired or congenital.
55 ;;
56 ;;
57 ;; 18. ENDOCRINE: Describe disease of thyroid, pituitary, adrenals,
58 ;; gonads, other body systems affected, etc.
59 ;;
60 ;;
61 ;; 19. NEUROLOGICAL: Cerebrum - orientation and memory. Cerebellum -
62 ;; gait, stance, coordination. Spinal Cord - deep tendon reflexes,
63 ;; pain, touch, temperature, vibration, position. Cranial
64 ;; nerves - I-XII. If abnormalities are found, describe region
65 ;; of CNS affected.
66 ;;
67 ;;
68 ;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
69 ;; response, emotional reaction, signs of tension and response to
70 ;; social and occupational capacity. State whether the veteran
71 ;; is capable of managing his or her benefit payments in his or
72 ;; her own best interest without restriction. (A physical
73 ;; disability which prevents the veteran from attending to
74 ;; financial matters in person is not a proper basis for a finding
75 ;; of incompetency unless the veteran is, by reason of that
76 ;; disability, incapable of directing someone else in handling
77 ;; the individual's financial affairs.)
78 ;;
79 ;;
80 ;;D. Diagnostic And Clinical Tests:
81 ;;
82 ;; 1. As indicated - e.g., parasite studies, X-rays of joints, etc.
83 ;; 2. Include results of all diagnostic and clinical tests conducted
84 ;; in the examination report.
85 ;;
86 ;;
87 ;;E. Diagnosis:
88 ;;
89 ;;1. Complete, review and comment on all laboratory and diagnostic tests.
90 ;;
91 ;;2. Provide diagnoses.
92 ;;
93 ;;3. Where some evidence indicates the disability may not have been
94 ;; incurred in service, please provide an opinion as to whether
95 ;; the disease or injury was at least as likely as not incurred
96 ;; in service. Please base your opinion on sound medical reasoning
97 ;; and complete consideration of all the evidence of record.
98 ;; Please discuss your reasoning and the evidence you considered in
99 ;; formulating your opinion.
100 ;;
101 ;;
102 ;;Signature: Date:
103 ;;
104 ;;___________________________________________________________
105 ;;END
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