source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRO1.m@ 1076

DVBCWRO1 ;ALB/ESW RESPIRATORY WKS TEXT - 1 ; 6 OCT 2000
 ;;2.7;AMIE;**34**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A. Review of Medical Records:
 ;;
 ;;B. Medical History (Subjective Complaints):
 ;;    Comment on:
 ;;
 ;;    1. Productive cough, sputum, hemoptysis, and/or anorexia.
 ;;    2. Extent of dyspnea on exertion.
 ;;    3. If veteran is asthmatic, report frequency of attacks and 
 ;;       baseline functional status between attacks.
 ;;    4. Treatment (type, frequency and duration including a need for 
 ;;       oxygen), response, side effects.
 ;;    5. Describe frequency and duration of any periods of incapacitation 
 ;;       (defined as requiring bed rest and treatment by a physician).
 ;;
 ;;C. Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following as appropriate to the condition 
 ;;    being examined and fully describe current findings:
 ;;
 ;;    1. Presence of cor pulmonale, RVH, or pulmonary hypertension.
 ;;    2. Weight loss or gain.
 ;;    3. For restrictive disease, describe condition underlying restrictive
 ;;       disease, e.g., kyphoscoliosis, pectus excavatum, etc., unless already
 ;;       of record.
 ;;
 ;;D. Diagnostic and Clinical Tests:
 ;;Provide:
 ;;
 ;;1. PULMONARY FUNCTION TESTS (unless carried out within past six months and
 ;;   the report is either in the claims folder or will be attached to this
 ;;   examination report, e.g., PFT's were in VAMC records at your facility).
 ;;   Spirometric pulmonary function testing should include FVC,FEV-1, and
 ;;   the FEV-1/FVC ratio. Both pre- and post-bronchodilatation test results should
 ;;   be reported. If post-bronchodilatation testing is not conducted
 ;;   in a particular case, please provide an explanation of why not. A DLCO may
 ;;   or may not be done routinely as part of pulmonary function testing
 ;;   at a particular facility. If there is a disparity between the results of
 ;;   different tests, please indicate which tests are more likely to accurately
 ;;   reflect the severity of the condition.
 ;;TOF
 ;;     DLCO note:
 ;;     If the DLCO was not done as a routine part of pulmonary function testing,
 ;;     the examiner should use his or her judgment, based on the specific
 ;;     condition (e.g., whether it is obstructive, interstitial, etc.) and
 ;;     other available information about the condition, as to whether a DLCO test
 ;;     is needed, since it is not useful in all situations. If it may provide
 ;;     useful information about the severity of the condition, it should be
 ;;     requested and reviewed before the examination report is submitted.
 ;;     If the examiner determines that the DLCO test is not needed, a statement
 ;;     as to why not (e.g., there are decreased lung volumes that would not yield
 ;;     valid test results) should be included in the report. Such a statement
 ;;     could avoid a remand from BVA when the test is not done. However,
 ;;     in the case of a BVA remand in which the DLCO is requested, the DLCO MUST
 ;;     be done unless there is a medical contraindication.
 ;; 
 ;;2. Chest X-ray (if no recent results available).
 ;;3. Include results of all diagnostic and clinical tests conducted
 ;;   in the examination report.
 ;;
 ;;E. Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END