75 lines
2.6 KiB
Mathematica
75 lines
2.6 KiB
Mathematica
DVBCWRW1 ;ALB/CMM RESPIRATORY 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. Productive cough, sputum, hemoptysis, and/or anorexia.
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;;
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;;
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;; 2. Extent of dyspnea on exertion.
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;;
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;;
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;; 3. If veteran is asthmatic, report frequency of attacks and
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;; baseline functional status between attacks.
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;;
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;;
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;; 4. Treatment (type, frequency and duration including a need for
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;; oxygen), response, side effects.
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;;
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;;
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;; 5. Describe frequency and duration of any periods of incapacitation
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;; (defined as requiring bed rest and treatment by a physician).
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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. Presence of cor pulmonale, RVH, or pulmonary hypertension.
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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. For restrictive disease, describe condition underlying
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;; restrictive disease, e.g., kyphoscoliosis, pectus excavatum,
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;; etc., unless already of record.
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;;
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;;TOF
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;;D. Diagnostic and Clinical Tests:
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;;
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;; Provide:
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;; 1. PULMONARY FUNCTION TESTS (unless carried out within past six
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;; months and the report is either in the claims folder or will
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;; be attached to this examination report). 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. Chest X-ray (if no recent results available).
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;; 3. 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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