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1DVBCWGX1 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**26**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;NARRATIVE: This is a comprehensive base-line or screening examination for
7 ;;all body systems, not just specific conditions claimed by the veteran.
8 ;;It is often the initial post-discharge examination of a veteran requested
9 ;;by the Compensation and Pension Service for disability compensation
10 ;;purposes. As a screening examination, it is not meant to elicit the
11 ;;detailed information about specific conditions that is necessary for rating
12 ;;purposes. Therefore, all claimed conditions, and any found or suspected
13 ;;conditions that were not claimed, should be addressed by referring to
14 ;;and following all appropriate worksheets, in addition to this one, to
15 ;;assure that the examination for each condition provides information
16 ;;adequate for rating purposes. This does not require that a medical
17 ;;specialist conduct examinations based on other worksheets, except in the
18 ;;case of vision and hearing problems, mental disorders, or especially
19 ;;complex or unusual problems. VISION, HEARING, AND MENTAL DISORDER
20 ;;EXAMINATIONS MUST BE CONDUCTED BY A SPECIALIST. The examiner may request
21 ;;any additional studies or examinations needed for proper diagnosis and
22 ;;evaluation (see other worksheets for guidance). All important negatives
23 ;;should be reported. The regional office may also request a general medical
24 ;;examination as evidence for nonservice-connected disability pension claims
25 ;;or for claimed entitlement to individual unemployability benefits in
26 ;;service-connected disability compensation claims. Barring unusual
27 ;;problems, examinations for pension should generally be adequate if only
28 ;;this general worksheet is followed.
29 ;;
30 ;;
31 ;;A. REVIEW OF MEDICAL RECORDS: Indicate whether the C-file was reviewed.
32 ;;
33 ;;
34 ;;
35 ;;B. MEDICAL HISTORY (Subjective Complaints):
36 ;;
37 ;; 1. Discuss: Whether an injury or disease that is found OCCURRED
38 ;; DURING ACTIVE SERVICE, BEFORE ACTIVE SERVICE, OR AFTER ACTIVE
39 ;; SERVICE. To the extent possible, describe the circumstances,
40 ;; dates, specific injury or disease that occurred, treatment,
41 ;; follow-up, and residuals. If the injury or disease occurred
42 ;; BEFORE ACTIVE SERVICE, describe any worsening of residuals due
43 ;; to being in military service. Describe current symptoms and
44 ;; treatment.
45 ;;
46 ;;
47 ;; 2. Occupational history (for PENSION and INDIVIDUAL UMEMPLOYABILITY
48 ;; claims): Obtain the name and address of employers (list most
49 ;; current first), type of occupation, employment dates, and wages
50 ;; for last 12 months. If any time was lost from work in the past
51 ;; 12-month period, please describe the reason and the extent of
52 ;; time lost.
53 ;;
54 ;;
55 ;; 3. Describe details of current treatment, conditions being treated,
56 ;; and side effects of treatment.
57 ;;
58 ;;
59 ;; 4. Describe all surgery and hospitalizations in and after service
60 ;; with approximate dates.
61 ;;
62 ;;
63 ;; 5. If a malignant neoplasm is or was present, provide:
64 ;; a. Date of confirmed diagnosis.
65 ;;
66 ;;
67 ;; b. Date of the last surgical, X-ray, antineoplastic chemotherapy,
68 ;; radiation, or other therapeutic procedure.
69 ;;
70 ;;
71 ;; c. State expected date treatment regimen is to be completed.
72 ;;
73 ;;
74 ;; d. If treatment is already completed, provide date of last treatment.
75 ;;
76 ;;
77 ;; e. If treatment is already completed, fully describe residuals.
78 ;;
79 ;;
80 ;;
81 ;;C. PHYSICAL EXAMINATION (Objective Findings):
82 ;;
83 ;; Address each of the following and fully describe current findings:
84 ;; The examiner should incorporate results of all ancillary studies
85 ;; into the final diagnoses.
86 ;;
87 ;; 1. VS: Heart rate, blood pressure (see #13 below), respirations,
88 ;; height, weight, maximum weight in past year, weight change in
89 ;; past year, body build, and state of nutrition.
90 ;;
91 ;;
92 ;; 2. DOMINANT HAND: Indicate the dominant hand and how this was
93 ;; determined, e.g., writes, eats, combs hair with that hand.
94 ;;
95 ;;
96 ;; 3. POSTURE AND GAIT: Describe abnormality and reason for it.
97 ;; Describe any ambulatory aids.
98 ;;
99 ;;
100 ;; 4. SKIN, INCLUDING APPENDAGES: If abnormal, describe appearance,
101 ;; location, extent of lesions. If there are laceration or burn
102 ;; scars, describe the location, exact measurements (cm. x cm.),
103 ;; shape, depression, type of tissue loss, adherence, and tenderness.
104 ;; For each burn scar, state if due to a 2nd or 3rd degree burn.
105 ;; Describe any limitation of activity or limitation of motion
106 ;; due to scarring or other skin lesions.
107 ;; NOTE: If there are disfiguring scars (of face, head, or neck),
108 ;; obtain COLOR PHOTOGRAPHS of the affected area(s) to submit
109 ;; with the examination report.
110 ;;
111 ;;
112 ;; 5. HEMIC AND LYMPHATIC: Describe adenopathy, tenderness,
113 ;; suppuration, edema, pallor, etc.
114 ;;
115 ;;
116 ;; 6. HEAD AND FACE: Describe scars, skin lesions, deformities, etc.,
117 ;; as discussed under item #4.
118 ;;
119 ;;
120 ;; 7. EYES: Describe external eye, pupil reaction, eye movements.
121 ;;
122 ;;
123 ;; 8. EARS: Describe canals, drums, perforations, discharge.
124 ;;
125 ;;
126 ;; 9. NOSE, SINUSES, MOUTH AND THROAT: Include gross dental findings.
127 ;; For sinusitis, describe headaches, pain, episodes of
128 ;; incapacitation, frequency and duration of antibiotic treatment.
129 ;;
130 ;;
131 ;; 10. NECK: Describe lymph nodes, thyroid, etc.
132 ;;
133 ;;
134 ;; 11. CHEST: Inspection, palpation, percussion, auscultation. Describe
135 ;; respiratory symptoms and effect on daily activities, e.g., how
136 ;; far the veteran can walk, how many flights of stairs veteran
137 ;; can climb. If a respiratory condition is claimed or suspected,
138 ;; refer to appropriate worksheet(s). Most respiratory conditions
139 ;; will require PFT's, including post-bronchodilation studies.
140 ;; Describe in detail any treatment for pulmonary disease.
141 ;;
142 ;;
143 ;; 12. BREAST: Describe masses, scars, nipple discharge, skin
144 ;; abnormalities. Give date of last mammogram, if any. Describe
145 ;; any breast surgery (with approximate date) and residuals.
146 ;;
147 ;;
148 ;; 13. CARDIOVASCULAR: NOTE: If there is evidence of a cardiovascular
149 ;; disease, or one is claimed, refer to appropriate worksheet(s).
150 ;;
151 ;; a. Record pulse, quality of heart sounds, abnormal heart sounds,
152 ;; arrhythmias. Describe symptoms and treatment for any
153 ;; cardiovascular conditions, including peripheral arterial
154 ;; and venous disease. Give NYHA classification of heart disease.
155 ;; A determination of METS by exercise testing may be required
156 ;; for certain cardiovascular conditions, and an estimation of
157 ;; METS may be required if exercise testing cannot be conducted
158 ;; for medical reasons. (See the cardiovascular worksheet
159 ;; for further guidance.)
160 ;;
161 ;;
162 ;; b. Describe the status of peripheral vessels and pulses.
163 ;; Describe edema, stasis pigmentation or eczema, ulcers, or
164 ;; other skin or nail abnormalities. Describe varicose veins,
165 ;; including extent to which any resulting edema is relieved
166 ;; by elevation of extremity. Examine for evidence of residuals
167 ;; of cold injury when indicated. See and follow special cold
168 ;; injury examination worksheet if there is a history of cold
169 ;; exposure in service and the special cold injury examination
170 ;; has not been previously done.
171 ;;
172 ;;
173 ;; c. BLOOD PRESSURE: (Per the rating schedule, hypertension means
174 ;; that the diastolic blood pressure is predominantly 90 mm.
175 ;; or greater, and isolated systolic hypertension means that
176 ;; the systolic blood pressure is predominantly 160 mm. or
177 ;; greater with a diastolic blood pressure of less than 90 mm.)
178 ;;
179 ;; 1) If the diagnosis of hypertension has not been previously
180 ;; established, and it is a claimed issue, B.P. readings
181 ;; MUST be taken two or more times on each of at least
182 ;; three different days.
183 ;;
184 ;;
185 ;; 2) If hypertension has been previously diagnosed and is
186 ;; claimed, but the claimant is not on treatment, B.P.
187 ;; readings MUST be taken two or more times on each of
188 ;; at least three different days.
189 ;;
190 ;;
191 ;; 3) If hypertension has been previously diagnosed, and the
192 ;; claimant is on treatment, take three blood pressure
193 ;; readings on the day of the examination.
194 ;;TOF
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