source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWSM1.m@ 638

DVBCWSM1 ;ALB/CMM RESPIRATORY, MISC. DISEASES WKS TEXT - 1 ;7 Oct 2000
 ;;2.7;AMIE;**34**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A. Review of Medical Records:
 ;;
 ;;B. Medical History (Subjective Complaints):
 ;;     Comment on:
 ;;
 ;;     1. Fever and/or night sweats.
 ;;     2. Weight loss or gain.
 ;;     3. Daytime hypersomnolence.
 ;;     4. Hemoptysis.
 ;;     5. Describe current treatment such as anticoagulant, tracheostomy, CPAP,
 ;;        oxygen, or antimicrobial therapy.
 ;;     6. If malignant disease, state initial treatment date, site of original
 ;;        tumor, type of tumor, types of treatment used, and date treatment is
 ;;        expected to end. If treatment has been completed, state date treatment
 ;;        was completed.
 ;;
 ;;C. Physical Examination (Objective Findings):
 ;;     Address each of the following as appropriate to the condition being
 ;;     examined and fully describe current findings:
 ;;
 ;;     1. Pulmonary Hypertension, RVH, cor pulmonale, or congestive heart failure.
 ;;     2. Residuals of pulmonary embolism.
 ;;     3. Respiratory Failure.
 ;;     4. Evidence of chronic pulmonary thromboembolism.
 ;;     5. If ankylosing spondylitis, is there restriction of the chest excursion
 ;;        and dyspnea on minimal exertion?
 ;;     6. Describe all residuals of malignancy including those due to treatment.
 ;;
 ;;D. Diagnostic and Clinical Tests:
 ;;
 ;;1. Pulmonary Function Tests, if indicated. The FEV-1,FVC, and FEV-1/FVC should
 ;;   be included. Both pre- and post-bronchodilatation pulmonary function
 ;;   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. 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 BVA remand in which DLCO
 ;;     is requested, the DLCO MUST be done unless there is a medical
 ;;     contraindication.
 ;;
 ;;     2. If sleep apnea is suspected, order Sleep Studies.
 ;;     3. Chest X-ray if necessary to document sarcoidosis or other parenchymal
 ;;        disease.
 ;;     4. Include results of all diagnostic and clinical tests conducted in
 ;;        the examination report.
 ;;
 ;;E. Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END