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1DVBCWSM1 ;ALB/CMM RESPIRATORY, MISC. DISEASES WKS TEXT - 1 ;7 Oct 2000
2 ;;2.7;AMIE;**34**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;; Comment on:
10 ;;
11 ;; 1. Fever and/or night sweats.
12 ;; 2. Weight loss or gain.
13 ;; 3. Daytime hypersomnolence.
14 ;; 4. Hemoptysis.
15 ;; 5. Describe current treatment such as anticoagulant, tracheostomy, CPAP,
16 ;; oxygen, or antimicrobial therapy.
17 ;; 6. If malignant disease, state initial treatment date, site of original
18 ;; tumor, type of tumor, types of treatment used, and date treatment is
19 ;; expected to end. If treatment has been completed, state date treatment
20 ;; was completed.
21 ;;
22 ;;C. Physical Examination (Objective Findings):
23 ;; Address each of the following as appropriate to the condition being
24 ;; examined and fully describe current findings:
25 ;;
26 ;; 1. Pulmonary Hypertension, RVH, cor pulmonale, or congestive heart failure.
27 ;; 2. Residuals of pulmonary embolism.
28 ;; 3. Respiratory Failure.
29 ;; 4. Evidence of chronic pulmonary thromboembolism.
30 ;; 5. If ankylosing spondylitis, is there restriction of the chest excursion
31 ;; and dyspnea on minimal exertion?
32 ;; 6. Describe all residuals of malignancy including those due to treatment.
33 ;;
34 ;;D. Diagnostic and Clinical Tests:
35 ;;
36 ;;1. Pulmonary Function Tests, if indicated. The FEV-1,FVC, and FEV-1/FVC should
37 ;; be included. Both pre- and post-bronchodilatation pulmonary function
38 ;; test results should be reported. If post-bronchodilatation testing is not
39 ;; conducted in a particular case, please provide an explanation of why not.
40 ;; A DLCO may or may not be done routinely as part of pulmonary function
41 ;; testing at a particular facility. If there is a disparity between the results
42 ;; of different tests, please indicate which tests are more likely to
43 ;; accurately reflect the severity of the condition.
44 ;;
45 ;;TOF
46 ;; DLCO note: If the DLCO was not done as a routine part of pulmonary
47 ;; function testing, the examiner should use his or her judgment, based on
48 ;; the specific condition (e.g., whether it is obstructive, interstitial,
49 ;; etc.) and other available information about the condition, as to whether
50 ;; a DLCO test is needed. If it may provide useful information about the
51 ;; severity of the condition, it should be requested and reviewed before
52 ;; the examination report is submitted. If the examiner determines that
53 ;; the DLCO test is not needed, a statement as to why not (e.g., there are
54 ;; decreased lung volumes that would not yield valid test results) should be
55 ;; included in the report. Such a statement could avoid a remand from BVA when
56 ;; the test is not done. However, in the case of BVA remand in which DLCO
57 ;; is requested, the DLCO MUST be done unless there is a medical
58 ;; contraindication.
59 ;;
60 ;; 2. If sleep apnea is suspected, order Sleep Studies.
61 ;; 3. Chest X-ray if necessary to document sarcoidosis or other parenchymal
62 ;; disease.
63 ;; 4. Include results of all diagnostic and clinical tests conducted in
64 ;; the examination report.
65 ;;
66 ;;E. Diagnosis:
67 ;;
68 ;;
69 ;;Signature: Date:
70 ;;END
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