source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWRW1.m@ 1780

DVBCWRW1 ;ALB/CMM RESPIRATORY WKS TEXT - 1 ; 6 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Comment on:

 ;;    1.  Productive cough, sputum, hemoptysis, and/or anorexia.

 ;;

 ;;

 ;;    2.  Extent of dyspnea on exertion.

 ;;

 ;;

 ;;    3.  If veteran is asthmatic, report frequency of attacks and 

 ;;        baseline functional status between attacks.

 ;;

 ;;

 ;;    4.  Treatment (type, frequency and duration including a need for 

 ;;        oxygen), response, side effects.

 ;;

 ;;

 ;;    5.  Describe frequency and duration of any periods of incapacitation 

 ;;        (defined as requiring bed rest and treatment by a physician).

 ;;

 ;;

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    Address each of the following as appropriate to the condition 

 ;;    being examined and fully describe current findings:

 ;;    1.  Presence of cor pulmonale, RVH, or pulmonary hypertension.

 ;;

 ;;

 ;;    2.  Weight loss or gain.

 ;;

 ;;

 ;;    3.  For restrictive disease, describe condition underlying 

 ;;        restrictive disease, e.g., kyphoscoliosis, pectus excavatum, 

 ;;        etc., unless already of record.

 ;;

 ;;TOF

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    Provide:

 ;;    1.  PULMONARY FUNCTION TESTS (unless carried out within past six 

 ;;        months and the report is either in the claims folder or will 

 ;;        be attached to this examination report).  When the results of

 ;;        pre-bronchodilator pulmonary function tests are NORMAL, post-

 ;;        bronchodilator studies are not required for VA evaluation 

 ;;        purposes.  IN ALL OTHER CASES, post-bronchodilator studies 

 ;;        should be conducted unless contraindicated (because of allergy

 ;;        to medication, etc.) or if the veteran was on bronchodilators

 ;;        before the test and had taken his or her medication within a 

 ;;        few hours of the study.  An examiner who determines that a 

 ;;        post-bronchodilator study should not be performed should 

 ;;        provide an explanation of why not.  If there is a disparity 

 ;;        between the results of different pulmonary function tests 

 ;;        (FEV-1, FVC, etc.), the examiner should indicate which test 

 ;;        result is the best indicator of the veteran's level of 

 ;;        pulmonary functioning.

 ;;    2.  Chest X-ray (if no recent results available).

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

 ;;        in the examination report.

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;

 ;;Signature:                             Date:

 ;;END