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1DVBCWRM1 ;ALB/CMM RESPIRATORY, MISC. DISEASES WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Fever and/or night sweats.
14 ;;
15 ;;
16 ;; 2. Weight loss or gain.
17 ;;
18 ;;
19 ;; 3. Daytime hypersomnolence.
20 ;;
21 ;;
22 ;; 4. Hemoptysis.
23 ;;
24 ;;
25 ;; 5. Describe current treatment such as anticoagulant, tracheostomy,
26 ;; CPAP, oxygen, or antimicrobial therapy.
27 ;;
28 ;;
29 ;; 6. If malignant disease, state initial treatment date, site of
30 ;; original tumor, type of tumor, types of treatment used, and
31 ;; date treatment is expected to end. If treatment has been
32 ;; completed, state date treatment was completed.
33 ;;
34 ;;
35 ;;C. Physical Examination (Objective Findings):
36 ;;
37 ;; Address each of the following as appropriate to the condition
38 ;; being examined and fully describe current findings:
39 ;; 1. Pulmonary Hypertension, RVH, cor pulmonale, or congestive
40 ;; heart failure.
41 ;;
42 ;;
43 ;; 2. Residuals of pulmonary embolism.
44 ;;
45 ;;
46 ;; 3. Respiratory Failure.
47 ;;
48 ;;
49 ;; 4. Evidence of chronic pulmonary thromboembolism.
50 ;;
51 ;;
52 ;; 5. If ankylosing spondylitis, is there restriction of the chest
53 ;; excursion and dyspnea on minimal exertion?
54 ;;
55 ;;
56 ;; 6. Describe all residuals of malignancy including those due to
57 ;; treatment.
58 ;;
59 ;;
60 ;;D. Diagnostic and Clinical Tests:
61 ;;
62 ;; 1. Pulmonary Function Tests, if indicated. When the results of
63 ;; pre-bronchodilator pulmonary function tests are NORMAL, post-
64 ;; bronchodilator studies are not required for VA evaluation
65 ;; purposes. IN ALL OTHER CASES, post-bronchodilator studies
66 ;; should be conducted unless contraindicated (because of allergy
67 ;; to medication, etc.) or if the veteran was on bronchodilators
68 ;; before the test and had taken his or her medication within a
69 ;; few hours of the study. An examiner who determines that a
70 ;; post-bronchodilator study should not be performed should
71 ;; provide an explanation of why not. If there is a disparity
72 ;; between the results of different pulmonary function tests
73 ;; (FEV-1, FVC, etc.), the examiner should indicate which test
74 ;; result is the best indicator of the veteran's level of
75 ;; pulmonary functioning.
76 ;; 2. If sleep apnea is suspected, order SLEEP STUDIES.
77 ;; 3. Chest X-ray if necessary to document sarcoidosis or other
78 ;; parenchymal disease.
79 ;; 4. Include results of all diagnostic and clinical tests conducted
80 ;; in the examination report
81 ;;
82 ;;
83 ;;E. Diagnosis:
84 ;;
85 ;;
86 ;;Signature: Date:
87 ;;END
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