VistA-WorldVistAEHR/r/AUTOMATED_MED_INFO_EXCHANGE.../DVBCWSM1.m

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DVBCWSM1 ;ALB/CMM RESPIRATORY, MISC. DISEASES WKS TEXT - 1 ;7 Oct 2000
;;2.7;AMIE;**34**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;B. Medical History (Subjective Complaints):
;; Comment on:
;;
;; 1. Fever and/or night sweats.
;; 2. Weight loss or gain.
;; 3. Daytime hypersomnolence.
;; 4. Hemoptysis.
;; 5. Describe current treatment such as anticoagulant, tracheostomy, CPAP,
;; oxygen, or antimicrobial therapy.
;; 6. If malignant disease, state initial treatment date, site of original
;; tumor, type of tumor, types of treatment used, and date treatment is
;; expected to end. If treatment has been completed, state date treatment
;; was completed.
;;
;;C. Physical Examination (Objective Findings):
;; Address each of the following as appropriate to the condition being
;; examined and fully describe current findings:
;;
;; 1. Pulmonary Hypertension, RVH, cor pulmonale, or congestive heart failure.
;; 2. Residuals of pulmonary embolism.
;; 3. Respiratory Failure.
;; 4. Evidence of chronic pulmonary thromboembolism.
;; 5. If ankylosing spondylitis, is there restriction of the chest excursion
;; and dyspnea on minimal exertion?
;; 6. Describe all residuals of malignancy including those due to treatment.
;;
;;D. Diagnostic and Clinical Tests:
;;
;;1. Pulmonary Function Tests, if indicated. The FEV-1,FVC, and FEV-1/FVC should
;; be included. Both pre- and post-bronchodilatation pulmonary function
;; test results should be reported. If post-bronchodilatation testing is not
;; conducted in a particular case, please provide an explanation of why not.
;; A DLCO may or may not be done routinely as part of pulmonary function
;; testing at a particular facility. If there is a disparity between the results
;; of different tests, please indicate which tests are more likely to
;; accurately reflect the severity of the condition.
;;
;;TOF
;; DLCO note: If the DLCO was not done as a routine part of pulmonary
;; function testing, the examiner should use his or her judgment, based on
;; the specific condition (e.g., whether it is obstructive, interstitial,
;; etc.) and other available information about the condition, as to whether
;; a DLCO test is needed. If it may provide useful information about the
;; severity of the condition, it should be requested and reviewed before
;; the examination report is submitted. If the examiner determines that
;; the DLCO test is not needed, a statement as to why not (e.g., there are
;; decreased lung volumes that would not yield valid test results) should be
;; included in the report. Such a statement could avoid a remand from BVA when
;; the test is not done. However, in the case of BVA remand in which DLCO
;; is requested, the DLCO MUST be done unless there is a medical
;; contraindication.
;;
;; 2. If sleep apnea is suspected, order Sleep Studies.
;; 3. Chest X-ray if necessary to document sarcoidosis or other parenchymal
;; disease.
;; 4. Include results of all diagnostic and clinical tests conducted in
;; the examination report.
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END