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1DVBCWGX2 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
2 ;;2.7;AMIE;**26**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;; 4) If hypertension has not been claimed, take three blood
7 ;; pressure readings on the day of the examination. If they
8 ;; are suggestive of hypertension or are borderline, readings
9 ;; MUST be taken two or more times on each of at least two
10 ;; additional days to rule hypertension in or out.
11 ;;
12 ;;
13 ;; 5) In the diagnostic summary, state whether hypertension is
14 ;; ruled in or out after completing these B.P. measurements.
15 ;; Describe treatment for hypertension and side effects. If
16 ;; hypertensive heart disease is suspected or found, follow
17 ;; worksheet for Heart.
18 ;;
19 ;;
20 ;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
21 ;; Describe any organ enlargement, ventral hernia, mass,
22 ;; tenderness, etc.).
23 ;;
24 ;;
25 ;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
26 ;; testicles, epididymis, and spermatic cord. If there is a hernia,
27 ;; describe type, location, size, whether complete, reducible,
28 ;; recurrent, supported by truss or belt, and whether or not
29 ;; operable. Describe anal fissures, hemorrhoids, ulcerations,
30 ;; etc. Include digital exam of rectal walls and prostate.
31 ;;
32 ;;
33 ;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam, including inspection of
34 ;; introitus, vagina, and cervix, palpation of labia, vagina,
35 ;; cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear
36 ;; if none within past year. If unable to conduct an examination
37 ;; and Pap smear, or if there is a severe or complex problem
38 ;; refer to a specialist to complete the examination.
39 ;;
40 ;;
41 ;; 17. MUSCULOSKELETAL:
42 ;; a. For all joint or muscle disorders, state each muscle and
43 ;; joint affected.
44 ;;
45 ;;
46 ;; b. Separately examine and describe in detail each affected joint.
47 ;; Measure active and passive range of motion in degrees using a
48 ;; goniometer. In addition, provide an assessment of the effect
49 ;; on range of motion and joint function of pain, weakness, fatigue,
50 ;; or incoordination following repetitive use or during flare-ups.
51 ;; (See the appropriate musculoskeletal worksheet for more detail.)
52 ;; NOTE: The diagnosis of DEGENERATIVE OR TRAUMATIC ARTHRITIS OF
53 ;; ANY JOINT REQUIRES X-RAY CONFIRMATION, but once confirmed by
54 ;; X-ray, either in service or after service, no further X-rays
55 ;; of that joint are required for disability evaluation purposes.
56 ;;
57 ;;
58 ;; c. Describe swelling, effusion, tenderness, muscle spasm, joint
59 ;; laxity, muscle atrophy, fibrous or bony residual of fracture. If
60 ;; joint is ankylosed, describe the position and angle of fixation.
61 ;;
62 ;;
63 ;; d. Describe any mechanical aids used by veteran.
64 ;;
65 ;;
66 ;; e. If foot problems exit, also describe objective evidence of pain
67 ;; at rest and on manipulation, rigidity, spasm, circulatory
68 ;; disturbance, swelling, callus, loss of strength, and whether
69 ;; condition is acquired or congenital.
70 ;;
71 ;;
72 ;; f. If there is amputation of a part, see the appropriate worksheet.
73 ;;
74 ;;
75 ;; g. With disc disease, also describe any neurological findings.
76 ;;
77 ;;
78 ;;
79 ;; 18. ENDOCRINE: Describe signs and symptoms of any endocrine disease,
80 ;; effects on other body systems, and current and past treatment.
81 ;; See endocrine worksheets for further guidance.
82 ;;
83 ;;
84 ;; 19. NEUROLOGICAL: Assess orientation and memory, gait, stance, and
85 ;; coordination, cranial nerve functions. Assess deep tendon
86 ;; reflexes, pain, touch, temperature, vibration, and position,
87 ;; motor and sensory status of peripheral nerves. If neurological
88 ;; abnormalities are found on examination, or there is a history
89 ;; of seizures, refer to appropriate worksheet.
90 ;;
91 ;;
92 ;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
93 ;; response, emotional reaction, signs of tension and effects on
94 ;; social and occupational functioning. (This is meant to be a
95 ;; brief screening examination. If a mental disorder is CLAIMED,
96 ;; OR SUSPECTED BASED ON THE SCREENING, an examination for diagnosis
97 ;; and assessment should be conducted by a psychiatrist or
98 ;; psychologist). State whether the veteran is capable of managing
99 ;; his or her benefit payments in his or her own best interests
100 ;; without restriction. (A physical disability which prevents the
101 ;; veteran from attending to financial matters in person is not a
102 ;; proper basis for a finding of incompetency unless the veteran is,
103 ;; by reason of that disability, incapable of directing someone
104 ;; else in handling the individual's financial affairs).
105 ;;
106 ;;
107 ;;
108 ;;D. DIAGNOSTIC AND CLINICAL TESTS:
109 ;;
110 ;; 1. Include results of all diagnostic and clinical tests conducted
111 ;; in the examination report.
112 ;; 2. Review all test results before providing the summary and diagnosis.
113 ;; 3. Follow additional worksheets, as appropriate.
114 ;;
115 ;;
116 ;;
117 ;;E. DIAGNOSIS: Provide a summary list of all disabilities diagnosed.
118 ;; Include an interpretation of the results of all diagnostic and other
119 ;; tests conducted in the final summary and diagnosis. For each
120 ;; condition diagnosed, describe its effect on the veteran's usual
121 ;; occupation and daily activities.
122 ;;TOF
123 ;;E. DIAGNOSIS:
124 ;;
125 ;;
126 ;;
127 ;;Signature: Date:
128 ;;END
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