source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRW1.m@ 1744

DVBCWRW1 ;ALB/CMM RESPIRATORY WKS TEXT - 1 ; 6 MARCH 1997
 ;;2.7;AMIE;**12**;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.
 ;;
 ;;TOF
 ;;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).  When the results of
 ;;        pre-bronchodilator pulmonary function tests are NORMAL, post-
 ;;        bronchodilator studies are not required for VA evaluation 
 ;;        purposes.  IN ALL OTHER CASES, post-bronchodilator studies 
 ;;        should be conducted unless contraindicated (because of allergy
 ;;        to medication, etc.) or if the veteran was on bronchodilators
 ;;        before the test and had taken his or her medication within a 
 ;;        few hours of the study.  An examiner who determines that a 
 ;;        post-bronchodilator study should not be performed should 
 ;;        provide an explanation of why not.  If there is a disparity 
 ;;        between the results of different pulmonary function tests 
 ;;        (FEV-1, FVC, etc.), the examiner should indicate which test 
 ;;        result is the best indicator of the veteran's level of 
 ;;        pulmonary functioning.
 ;;    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