English French Notes Complete/Exclude salivary glands range of motion pain or tenderness nipple discharge Musculoskeletal - spine,upper and lower extremeties: mobility, tenderness, pain of spine joint pain joint swelling muscle weakness rheumatic fever shortness of breath pulmonary embolus configuration of thorax respiratiory movements inspiratory breath sounds expiratiory breath sounds heart inpulse chest pain/discomfort paroxysmal nocturnal dyspnea neck veins peripheral veins nausea and vomiting abdominal wall/distention/tenderness food intolerance bowel sounds ventral hernia gastric/marginal/duodenal ulcer urinary infection veneral disease inguinal canal Female: external genitalia abnormal menses vaginal discharge anus and sphincter test for occult blood MENTAL DISORDERS - POW PROTOCOL Physician's Guide Reference: Chapter 14, 17, 20 1. Immediate pre-military events - 2. Events as a POW - traumatic events as a POW, if not elsewhere SOCIAL WORK SURVEY - POW PROTOCOL Physician's Guide Reference: Chapter 17 A. Describe the veteran's personal appearance - B. Describe the veteran's personal health - C. Describe the veteran's family adjustment - D. Describe the veteran's community adjustment - E. Describe the veteran's economic adjustment - cranial nerves gait disturbance biceps reflex triceps reflex patellar reflex Achilles reflex plantar response peripheral nerves sensory change loss of consciousness memory change trouble with decisions sleep disturbance crying spells thoughts of suicide difficulty with work loss of appetite trouble with sex life social withdrawal improbable beliefs C. Summary of findings: PRISONER OF WAR PROTOCOL A. Medical history (include childhood and adult illnesses and B. Past history (include civilian and military occupation, military) history including geographic locations and dates, habits such as alcohol, tobacco and drugs, family history): C. System review (comment specifically if positive symptom): weight change fever or chills night sweats irritable bowel syndrome peptic ulcer PYELITIS, NEPHROLITHIASIS, URETEROLITHIASIS, URETERAL STRICTURE AND HYDRONEPHROSIS (GU) 4. Catheter drainage requirement (frequency of need) - RECTUM AND ANUS (DIGESTIVE) Diseases of the rectum, anal canal or perineum must be differentiated as to type. 8. Fecal leakage - 9. Frequency of episodes - EDIT C&P STATIC INFORMATION The status of this request is not NEW or PENDING, REPORTED. It cannot, therefore, be modified. Since you have modified the REMARKS section, a new copy of the request will be issued to the medical center tomorrow morning. 1,3,0,2:1,0^Insufficient link info not updated!...Priority restored Invalid user number (DUZ) DVBA C RELEASE 2507 You are not authorized to release 2507 requests!! is not complete 2507 Exam Release Please wait while the individual exam statuses are checked. All exams have been completed, please enter the following: Since there are still incomplete exams, this request cannot be released to the RO. Press RETURN or This request is now released. Release NOT COMPLETED !! This request has been cancelled by the RO. This request has been completed and transferred out. This request has been cancelled by MAS. This request has been released to the RO. This request has been printed by the RO. This request is new and has not yet been reported to MAS. COMPENSATION AND PENSION EXAM REQUEST Requested by 0,0,0,2:1,0^** Priority of exam: 0,0,0,0,0^Date original 2507 Reported to MAS: 0,0,0,3:2,0^Selected exams: Current Rated disabilities: General remarks: Unknown division Medical Center Division at *** Transferred from Date Requested: ** Claim folder review will be required ** VA Form 21-2507 General remarks (continued): No parameters in AMIE site parameter file! New 2507 Request Report for BDTRQ* EDTRQ* New Request Recap Sheet for Run Date C&P Diagnostic Test Order Record Initials Laboratory: Radiology: Other: Missing vet name Manual New C&P Request Printing Do you want just one request Enter Y for only one Vet or N for all Vets. Enter BEGINNING date of request: and ENDING date of request: Ending date is earlier than starting date! New C&P request printing New C&P Requests -- There were no new 2507 requests for for division C&P Request Modifications -- No modified requests to report. C&P Exams Added -- No added exams to report. Date of request: Enter MED CENTER DIVISION: C&P REQUESTS BY DATE RANGE Enter DATE OF REQUEST FROM: Do you want to report by physician Enter to report by Physician or to report only by date range. This report uses by Physician by Date Range EXAMINING PHYSICIAN RESPIRATORY MANIFESTATIONS OF DISEASES OF OTHER SYSTEMS An example of this type of exam is extremely unfavorable ankylosis of the thoracic spine that so severely restricts chest excursion that the veteran is dyspneic on minimal exertion OR abdominal tumor interferes with excursion of the diaphragm to such an extent that chronic passive congestion of one lung results. C. Objective findings : 1. Clinical findings - 2. Pulmonary function studies - Since this request has reopened, its status will be PENDING, REPORTED. Be sure to regenerate any exam worksheets that will be needed for this request. Press RETURN to continue Your user number (DUZ) is invalid ! Re-open Exams/Requests Status prohibits activity except by supervisors. 1,0,0,2,0^This 2507 was never reported to MAS, it can NOT be reopened. Do you want to reopen the ENTIRE request Enter Y to reopen the ENTIRE request or N to reopen only selected exams. Select EXAM TO REOPEN: Exam name not found in file 396.6 ! Already open! reopen error ! There are no cancelled or completed exams remaining on this request. Reopen error on Entire exam is now REOPENED. Reopen error ! Sending a bulletin to the 2507 REOPENED mail group ... DVBA C 2507 EXAM REOPENED This request has not been released. This reopen will not affect the AMIE AMIS 290. **THIS REOPEN WILL AFFECT THE AMIE AMIS 290** /Affects AMIE AMIS 290 G.DVBA C 2507 EXAM REOPENED@ I am sending updated information to Select Reprint Option - (D)ate or (V)eteran: D// Must be D or V Do you want just the Lab/X-ray results Enter Y to get just the Lab/X-ray results for the Vet or N to get the entire exam results AND Lab/X-ray. Enter original printing date: Reprinted by the RO or MAS ? >> Must be R for Regional Office or M for MAS. 2507 Final Exam Reprint Single 2507 Final Exam Reprint ** REPRINT OF FINAL ** Physician signature: ___________________________________ Date: _____________ SCARS, OTHER THAN BURNS (ORTHOPEDIC/DISFIGUREMENT) The type of injury or infection causing the wound or scar, its date, the treatment used and the response to such treatment should be described. Point of entrance and exit of missiles are important in evaluating injuries of nerves, vessels, and muscles. Photographs, if indicated, (see Physician's Guide, Paragraph 1.19) should be submitted. 2. Keloid formation, adherance, herniation - 3. Inflammation, swelling, depression, vascular supply, ulceration - 4. Tender and painful on objective demonstration - 5. Cosmetic effects (submit photographs of all facial and other significant scars) - 6. Limitation of function of part affected - SCHEDULE C&P EXAMS You have no user number ! This request has no exams on it and should be completely cancelled. This request has been completely transferred to another site. Scheduling will not be allowed. Scheduling has been completed for this request as of Only supervisors can change it. Do you want to change Enter Y to be able to change the scheduling information or N to backup. Note: One or more exams on this request have transferred out. Do you want to make an appointment for a clinic Schedule a Clinic Appointment for 2507 Exam Enter Y to make an appointment via ADT/Scheduling or N to skip. Enter Scheduling Information for 2507 Exams Has scheduling for all exams been completed Enter Y if scheduling is completed, N if not. Ok, then please complete the following: Important scheduling information is missing! 2507 file NOT updated! For SKIN, NOT ELSEWHERE CLASSIFIED Type of Exam: SKIN, NOT ELSEWHERE CLASSIFIED SKIN, OTHER THAN SCARS When furnishing the history of the present skin disease include a description of the skin changes, when the disorder first appeared, and the progression of the illness since that time. Note whether remissions or exacerbations occurred and whether they were related to the occupation or treatment. Include the duration of remissions and factors that may have influenced the course of the disorder. B. Subjective complaints: (List the types of complaints such as itching burning, pain and anesthesia. Note whether environmental factors such as temperature or seasonal change affect the severity of the symptoms.) 1. Description of skin disorder - 2. Distribution of skin disorder - 3. Configuration and characteristics of lesions - 4. Nervous manifestations - 5. Attach color photograph if condition is disfiguring. (Note: If current diagnosis differs from the skin condition for which the examination was ordered, then review prior records and express opinion whether current disease is a new problem or original diagnosis was in error.) SENSE OF SMELL Report whether loss is partial or complete and whether it is on an organic or psychiatric basis. If a psychiatric basis is suspected, a special psychiatric examination should be ordered. Substances used for testing olfaction and results (each side of nose should be tested separately): 4. Oil of lemon - 5. Other (state substance) - SPINE (ORTHOPEDIC) Complete description of spinal orthosis, its impact on motion before and after application, and whether the usage is constant or intermittent should be part of the To give uniformity in describing limitation of motion or ankylosis, THE USE OF A GONIOMETER IS REQUIRED. Report each spinal segment separately. 1. Postural abnormalities - 2. Fixed deformity - 3. Musculature of back - 4. Range of motion: a. Forward flexion - b. Backward extension - c. Left lateral flexion - d. Right lateral flexion - e. Rotation to left - f. Rotation to right - 5. Objective evidence of pain on motion - 6. Identify and describe any evidence of neurological involvement - SCARS, BURN When true third degree burn involvement is established, measure and describe all areas of scarring and all secondary #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################