88 lines
2.8 KiB
Mathematica
88 lines
2.8 KiB
Mathematica
DVBCWRM1 ;ALB/CMM RESPIRATORY, MISC. DISEASES WKS TEXT - 1 ; 6 MARCH 1997
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;;2.7;AMIE;**12**;Apr 10, 1995
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;
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;
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TXT ;
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;;A. Review of Medical Records:
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;;
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;;
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;;
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;;B. Medical History (Subjective Complaints):
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;;
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;; Comment on:
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;; 1. Fever and/or night sweats.
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;;
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;;
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;; 2. Weight loss or gain.
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;;
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;;
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;; 3. Daytime hypersomnolence.
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;;
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;;
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;; 4. Hemoptysis.
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;;
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;;
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;; 5. Describe current treatment such as anticoagulant, tracheostomy,
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;; CPAP, oxygen, or antimicrobial therapy.
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;;
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;;
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;; 6. If malignant disease, state initial treatment date, site of
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;; original tumor, type of tumor, types of treatment used, and
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;; date treatment is expected to end. If treatment has been
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;; completed, state date treatment was completed.
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;;
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;;
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;;C. Physical Examination (Objective Findings):
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;;
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;; Address each of the following as appropriate to the condition
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;; being examined and fully describe current findings:
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;; 1. Pulmonary Hypertension, RVH, cor pulmonale, or congestive
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;; heart failure.
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;;
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;;
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;; 2. Residuals of pulmonary embolism.
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;;
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;;
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;; 3. Respiratory Failure.
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;;
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;;
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;; 4. Evidence of chronic pulmonary thromboembolism.
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;;
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;;
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;; 5. If ankylosing spondylitis, is there restriction of the chest
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;; excursion and dyspnea on minimal exertion?
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;;
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;;
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;; 6. Describe all residuals of malignancy including those due to
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;; treatment.
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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. Pulmonary Function Tests, if indicated. When the results of
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;; pre-bronchodilator pulmonary function tests are NORMAL, post-
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;; bronchodilator studies are not required for VA evaluation
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;; purposes. IN ALL OTHER CASES, post-bronchodilator studies
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;; should be conducted unless contraindicated (because of allergy
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;; to medication, etc.) or if the veteran was on bronchodilators
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;; before the test and had taken his or her medication within a
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;; few hours of the study. An examiner who determines that a
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;; post-bronchodilator study should not be performed should
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;; provide an explanation of why not. If there is a disparity
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;; between the results of different pulmonary function tests
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;; (FEV-1, FVC, etc.), the examiner should indicate which test
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;; result is the best indicator of the veteran's level of
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;; pulmonary functioning.
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;; 2. If sleep apnea is suspected, order SLEEP STUDIES.
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;; 3. Chest X-ray if necessary to document sarcoidosis or other
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;; parenchymal disease.
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;; 4. 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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;;
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;;Signature: Date:
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;;END
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