source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWGX2.m@ 1780

DVBCWGX2 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997

 ;;2.7;AMIE;**26**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;            4) If hypertension has not been claimed, take three blood

 ;;               pressure readings on the day of the examination.  If they

 ;;               are suggestive of hypertension or are borderline, readings

 ;;               MUST be taken two or more times on each of at least two

 ;;               additional days to rule hypertension in or out.

 ;;

 ;;

 ;;            5) In the diagnostic summary, state whether hypertension is

 ;;               ruled in or out after completing these B.P. measurements.

 ;;               Describe treatment for hypertension and side effects.  If

 ;;               hypertensive heart disease is suspected or found, follow

 ;;               worksheet for Heart.

 ;;

 ;;

 ;;   14.  ABDOMEN:  Inspection, auscultation, palpation, percussion.  

 ;;        Describe any organ enlargement, ventral hernia, mass,

 ;;        tenderness, etc.).  

 ;;

 ;;

 ;;   15.  GENITAL/RECTAL (MALE):  Inspection and palpation of penis, 

 ;;        testicles, epididymis, and spermatic cord.  If there is a hernia, 

 ;;        describe type, location, size, whether complete, reducible, 

 ;;        recurrent, supported by truss or belt, and whether or not 

 ;;        operable.  Describe anal fissures, hemorrhoids, ulcerations,

 ;;        etc.  Include digital exam of rectal walls and prostate.

 ;;

 ;;

 ;;   16.  GENITAL/RECTAL (FEMALE):  Pelvic exam, including inspection of

 ;;        introitus, vagina, and cervix, palpation of labia, vagina,

 ;;        cervix, uterus, adnexa, and ovaries, rectal exam.  Do Pap smear

 ;;        if none within past year.  If unable to conduct an examination

 ;;        and Pap smear, or if there is a severe or complex problem

 ;;        refer to a specialist to complete the examination.

 ;;

 ;;

 ;;   17.  MUSCULOSKELETAL:

 ;;        a. For all joint or muscle disorders, state each muscle and 

 ;;           joint affected.

 ;;

 ;;

 ;;        b. Separately examine and describe in detail each affected joint.

 ;;           Measure active and passive range of motion in degrees using a

 ;;           goniometer.  In addition, provide an assessment of the effect

 ;;           on range of motion and joint function of pain, weakness, fatigue,

 ;;           or incoordination following repetitive use or during flare-ups.

 ;;           (See the appropriate musculoskeletal worksheet for more detail.)

 ;;           NOTE: The diagnosis of DEGENERATIVE OR TRAUMATIC ARTHRITIS OF

 ;;           ANY JOINT REQUIRES X-RAY CONFIRMATION, but once confirmed by

 ;;           X-ray, either in service or after service, no further X-rays

 ;;           of that joint are required for disability evaluation purposes.

 ;;

 ;;

 ;;        c. Describe swelling, effusion, tenderness, muscle spasm, joint

 ;;           laxity, muscle atrophy, fibrous or bony residual of fracture. If

 ;;           joint is ankylosed, describe the position and angle of fixation.

 ;;

 ;;

 ;;        d. Describe any mechanical aids used by veteran.

 ;;

 ;;

 ;;        e. If foot problems exit, also describe objective evidence of pain

 ;;           at rest and on manipulation, rigidity, spasm, circulatory

 ;;           disturbance, swelling, callus, loss of strength, and whether

 ;;           condition is acquired or congenital.

 ;;

 ;;

 ;;        f. If there is amputation of a part, see the appropriate worksheet.

 ;;

 ;;

 ;;        g. With disc disease, also describe any neurological findings.

 ;;

 ;;

 ;;

 ;;   18.  ENDOCRINE:  Describe signs and symptoms of any endocrine disease,

 ;;        effects on other body systems, and current and past treatment.

 ;;        See endocrine worksheets for further guidance.

 ;;

 ;;

 ;;   19.  NEUROLOGICAL:  Assess orientation and memory, gait, stance, and

 ;;        coordination, cranial nerve functions.  Assess deep tendon 

 ;;        reflexes, pain, touch, temperature, vibration, and position,

 ;;        motor and sensory status of peripheral nerves.  If neurological

 ;;        abnormalities are found on examination, or there is a history

 ;;        of seizures, refer to appropriate worksheet.

 ;;

 ;;

 ;;   20.  PSYCHIATRIC:  Describe behavior, comprehension, coherence of 

 ;;        response, emotional reaction, signs of tension and effects on

 ;;        social and occupational functioning.  (This is meant to be a

 ;;        brief screening examination.  If a mental disorder is CLAIMED,

 ;;        OR SUSPECTED BASED ON THE SCREENING, an examination for diagnosis

 ;;        and assessment should be conducted by a psychiatrist or

 ;;        psychologist).  State whether the veteran is capable of managing

 ;;        his or her benefit payments in his or her own best interests

 ;;        without restriction.  (A physical disability which prevents the

 ;;        veteran from attending to financial matters in person is not a

 ;;        proper basis for a finding of incompetency unless the veteran is,

 ;;        by reason of that disability, incapable of directing someone

 ;;        else in handling the individual's financial affairs).

 ;;

 ;;

 ;;

 ;;D.  DIAGNOSTIC AND CLINICAL TESTS:

 ;;

 ;;    1.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;    2.  Review all test results before providing the summary and diagnosis.

 ;;    3.  Follow additional worksheets, as appropriate.

 ;;

 ;;

 ;;

 ;;E.  DIAGNOSIS:  Provide a summary list of all disabilities diagnosed.

 ;;    Include an interpretation of the results of all diagnostic and other

 ;;    tests conducted in the final summary and diagnosis.  For each

 ;;    condition diagnosed, describe its effect on the veteran's usual 

 ;;    occupation and daily activities.

 ;;TOF

 ;;E.  DIAGNOSIS:  

 ;;

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END