source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRW1.m@ 1639

Last change on this file since 1639 was 613, checked in by George Lilly, 15 years ago

initial load of WorldVistAEHR

File size: 2.6 KB
RevLine 
[613]1DVBCWRW1 ;ALB/CMM RESPIRATORY 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. Productive cough, sputum, hemoptysis, and/or anorexia.
14 ;;
15 ;;
16 ;; 2. Extent of dyspnea on exertion.
17 ;;
18 ;;
19 ;; 3. If veteran is asthmatic, report frequency of attacks and
20 ;; baseline functional status between attacks.
21 ;;
22 ;;
23 ;; 4. Treatment (type, frequency and duration including a need for
24 ;; oxygen), response, side effects.
25 ;;
26 ;;
27 ;; 5. Describe frequency and duration of any periods of incapacitation
28 ;; (defined as requiring bed rest and treatment by a physician).
29 ;;
30 ;;
31 ;;C. Physical Examination (Objective Findings):
32 ;;
33 ;; Address each of the following as appropriate to the condition
34 ;; being examined and fully describe current findings:
35 ;; 1. Presence of cor pulmonale, RVH, or pulmonary hypertension.
36 ;;
37 ;;
38 ;; 2. Weight loss or gain.
39 ;;
40 ;;
41 ;; 3. For restrictive disease, describe condition underlying
42 ;; restrictive disease, e.g., kyphoscoliosis, pectus excavatum,
43 ;; etc., unless already of record.
44 ;;
45 ;;TOF
46 ;;D. Diagnostic and Clinical Tests:
47 ;;
48 ;; Provide:
49 ;; 1. PULMONARY FUNCTION TESTS (unless carried out within past six
50 ;; months and the report is either in the claims folder or will
51 ;; be attached to this examination report). When the results of
52 ;; pre-bronchodilator pulmonary function tests are NORMAL, post-
53 ;; bronchodilator studies are not required for VA evaluation
54 ;; purposes. IN ALL OTHER CASES, post-bronchodilator studies
55 ;; should be conducted unless contraindicated (because of allergy
56 ;; to medication, etc.) or if the veteran was on bronchodilators
57 ;; before the test and had taken his or her medication within a
58 ;; few hours of the study. An examiner who determines that a
59 ;; post-bronchodilator study should not be performed should
60 ;; provide an explanation of why not. If there is a disparity
61 ;; between the results of different pulmonary function tests
62 ;; (FEV-1, FVC, etc.), the examiner should indicate which test
63 ;; result is the best indicator of the veteran's level of
64 ;; pulmonary functioning.
65 ;; 2. Chest X-ray (if no recent results available).
66 ;; 3. Include results of all diagnostic and clinical tests conducted
67 ;; in the examination report.
68 ;;
69 ;;
70 ;;E. Diagnosis:
71 ;;
72 ;;
73 ;;Signature: Date:
74 ;;END
Note: See TracBrowser for help on using the repository browser.