129 lines
5.8 KiB
Mathematica
129 lines
5.8 KiB
Mathematica
DVBCWGX2 ;ALB/JAM GENERAL MEDICAL WKS TEXT - 1 ; 5 MARCH 1997
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;;2.7;AMIE;**26**;Apr 10, 1995
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TXT ;
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;; 4) If hypertension has not been claimed, take three blood
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;; pressure readings on the day of the examination. If they
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;; are suggestive of hypertension or are borderline, readings
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;; MUST be taken two or more times on each of at least two
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;; additional days to rule hypertension in or out.
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;;
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;;
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;; 5) In the diagnostic summary, state whether hypertension is
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;; ruled in or out after completing these B.P. measurements.
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;; Describe treatment for hypertension and side effects. If
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;; hypertensive heart disease is suspected or found, follow
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;; worksheet for Heart.
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;;
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;;
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;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion.
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;; Describe any organ enlargement, ventral hernia, mass,
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;; tenderness, etc.).
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;;
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;;
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;; 15. GENITAL/RECTAL (MALE): Inspection and palpation of penis,
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;; testicles, epididymis, and spermatic cord. If there is a hernia,
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;; describe type, location, size, whether complete, reducible,
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;; recurrent, supported by truss or belt, and whether or not
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;; operable. Describe anal fissures, hemorrhoids, ulcerations,
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;; etc. Include digital exam of rectal walls and prostate.
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;;
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;;
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;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam, including inspection of
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;; introitus, vagina, and cervix, palpation of labia, vagina,
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;; cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear
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;; if none within past year. If unable to conduct an examination
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;; and Pap smear, or if there is a severe or complex problem
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;; refer to a specialist to complete the examination.
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;;
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;;
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;; 17. MUSCULOSKELETAL:
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;; a. For all joint or muscle disorders, state each muscle and
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;; joint affected.
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;;
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;;
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;; b. Separately examine and describe in detail each affected joint.
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;; Measure active and passive range of motion in degrees using a
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;; goniometer. In addition, provide an assessment of the effect
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;; on range of motion and joint function of pain, weakness, fatigue,
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;; or incoordination following repetitive use or during flare-ups.
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;; (See the appropriate musculoskeletal worksheet for more detail.)
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;; NOTE: The diagnosis of DEGENERATIVE OR TRAUMATIC ARTHRITIS OF
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;; ANY JOINT REQUIRES X-RAY CONFIRMATION, but once confirmed by
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;; X-ray, either in service or after service, no further X-rays
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;; of that joint are required for disability evaluation purposes.
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;;
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;;
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;; c. Describe swelling, effusion, tenderness, muscle spasm, joint
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;; laxity, muscle atrophy, fibrous or bony residual of fracture. If
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;; joint is ankylosed, describe the position and angle of fixation.
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;;
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;;
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;; d. Describe any mechanical aids used by veteran.
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;;
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;;
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;; e. If foot problems exit, also describe objective evidence of pain
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;; at rest and on manipulation, rigidity, spasm, circulatory
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;; disturbance, swelling, callus, loss of strength, and whether
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;; condition is acquired or congenital.
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;;
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;;
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;; f. If there is amputation of a part, see the appropriate worksheet.
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;;
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;;
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;; g. With disc disease, also describe any neurological findings.
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;;
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;;
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;;
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;; 18. ENDOCRINE: Describe signs and symptoms of any endocrine disease,
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;; effects on other body systems, and current and past treatment.
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;; See endocrine worksheets for further guidance.
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;;
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;;
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;; 19. NEUROLOGICAL: Assess orientation and memory, gait, stance, and
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;; coordination, cranial nerve functions. Assess deep tendon
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;; reflexes, pain, touch, temperature, vibration, and position,
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;; motor and sensory status of peripheral nerves. If neurological
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;; abnormalities are found on examination, or there is a history
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;; of seizures, refer to appropriate worksheet.
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;;
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;;
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;; 20. PSYCHIATRIC: Describe behavior, comprehension, coherence of
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;; response, emotional reaction, signs of tension and effects on
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;; social and occupational functioning. (This is meant to be a
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;; brief screening examination. If a mental disorder is CLAIMED,
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;; OR SUSPECTED BASED ON THE SCREENING, an examination for diagnosis
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;; and assessment should be conducted by a psychiatrist or
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;; psychologist). State whether the veteran is capable of managing
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;; his or her benefit payments in his or her own best interests
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;; without restriction. (A physical disability which prevents the
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;; veteran from attending to financial matters in person is not a
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;; proper basis for a finding of incompetency unless the veteran is,
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;; by reason of that disability, incapable of directing someone
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;; else in handling the individual's financial affairs).
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;;
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;;
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;;
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;;D. DIAGNOSTIC AND CLINICAL TESTS:
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;;
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;; 1. Include results of all diagnostic and clinical tests conducted
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;; in the examination report.
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;; 2. Review all test results before providing the summary and diagnosis.
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;; 3. Follow additional worksheets, as appropriate.
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;;
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;;
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;;
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;;E. DIAGNOSIS: Provide a summary list of all disabilities diagnosed.
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;; Include an interpretation of the results of all diagnostic and other
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;; tests conducted in the final summary and diagnosis. For each
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;; condition diagnosed, describe its effect on the veteran's usual
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;; occupation and daily activities.
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;;TOF
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;;E. DIAGNOSIS:
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;;
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;;
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;;
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;;Signature: Date:
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;;END
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