106 lines
4.8 KiB
Mathematica
106 lines
4.8 KiB
Mathematica
DVBCWP2 ;ALB/CMM POW, GENERAL WKS TEXT - 2 ; 7 MARCH 1997
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;;2.7;AMIE;**12,56**;Apr 10, 1995
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;
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;
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TXT ;
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;; 12. BREAST: Comment on any masses palpated in breast parenchyma
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;; including axillary tail. Comment on any skin abnormalities.
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;; Comment on any discharge from nipples.
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;;
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;;
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;; 13. CARDIOVASCULAR: Record pulse, heart sounds, abnormalities
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;; (i.e., arrhythmias, murmurs, etc.), and status of peripheral
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;; vessels. Note edema. Describe varicose veins including
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;; location, size, extent, ulcers, scars, and competency of deep
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;; circulation. Examine for evidence of residuals of frostbite
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;; when indicated. See cold injuries examination worksheet.
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;; (NOTE: Cardiovascular signs and symptoms should be graded
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;; using NYHA scale.)
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;;
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;;
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;; 14. ABDOMEN: Inspection, auscultation, palpation, percussion. If
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;; abnormal, describe (i.e., abdominal enlargement, masses,
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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 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). Inspection of anus for fissures, hemorrhoids,
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;; ulcerations, etc., and digital exam of rectal walls, and
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;; prostate.
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;;
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;;
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;; 16. GENITAL/RECTAL (FEMALE): Pelvic exam should include inspection
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;; of introitus, vagina, and cervix, palpation of labia, vagina,
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;; cervix, uterus, adnexa, and ovaries. Inspection of anus for
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;; fissures, hemorrhoids, ulcerations, etc., and digital exam of
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;; rectal walls. Any severe abnormalities may be referred to a
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;; specialist.
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;;
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;;
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;; 17. MUSCULOSKELETAL: For joint or muscle defects, describe location,
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;; swelling, atrophy, tenderness, active and passive motion in
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;; degrees using a goniometer, angle of fixation, fracture,
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;; fibrous or bony residual, and mechanical aids used by veteran.
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;; Provide an assessment of the effect on range of motion and
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;; joint function of pain, weakness, fatigue, or incoordination
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;; following repetitive use or during flare-ups. (See the
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;; appropriate worksheet for more detail.) If foot problems
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;; exist, perform above exam and also include objective evidence
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;; of pain at rest and on manipulation, rigidity, spasm,
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;; circulatory disturbance, swelling, callus, loss of strength,
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;; mobility of ankles and feet, and whether acquired or congenital.
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;;
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;;
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;; 18. ENDOCRINE: Describe disease of thyroid, pituitary, adrenals,
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;; gonads, other body systems affected, etc.
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;;
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;;
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;; 19. NEUROLOGICAL: Cerebrum - orientation and memory. Cerebellum -
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;; gait, stance, coordination. Spinal Cord - deep tendon reflexes,
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;; pain, touch, temperature, vibration, position. Cranial
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;; nerves - I-XII. If abnormalities are found, describe region
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;; of CNS affected.
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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 response to
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;; social and occupational capacity. State whether the veteran
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;; is capable of managing his or her benefit payments in his or
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;; her own best interest without restriction. (A physical
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;; disability which prevents the veteran from attending to
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;; financial matters in person is not a proper basis for a finding
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;; of incompetency unless the veteran is, by reason of that
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;; disability, incapable of directing someone else in handling
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;; the individual's financial affairs.)
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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. As indicated - e.g., parasite studies, X-rays of joints, etc.
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;; 2. Include results of all diagnostic and clinical tests conducted
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;; in the examination report.
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;;
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;;
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;;E. Diagnosis:
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;;
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;;1. Complete, review and comment on all laboratory and diagnostic tests.
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;;
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;;2. Provide diagnoses.
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;;
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;;3. Where some evidence indicates the disability may not have been
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;; incurred in service, please provide an opinion as to whether
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;; the disease or injury was at least as likely as not incurred
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;; in service. Please base your opinion on sound medical reasoning
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;; and complete consideration of all the evidence of record.
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;; Please discuss your reasoning and the evidence you considered in
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;; formulating your opinion.
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;;
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;;
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;;Signature: Date:
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;;
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;;___________________________________________________________
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;;END
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