308 lines
12 KiB
Plaintext
308 lines
12 KiB
Plaintext
English French Notes Complete/Exclude
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MISCELLANEOUS NEUROLOGICAL DISORDERS
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For MUSCULOSKELETAL, NOT ELSEWHERE CLASSIFIED
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Type of Exam: MUSCULOSKELETAL, NOT ELSEWHERE CLASSIFIED
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This 2507 already has appointments.
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Enter '?' for help
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Is this appointment due to a cancellation?
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Enter NO if the appointment is not a reschedule of another appointment
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made previously. Enter YES if the appointment is being scheduled because
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an appointment has been or will be canceled.
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'^' NOT ALLOWED
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You have not selected the linked appointment being rescheduled. You may
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need to adjust the link to the appointment with the AMIE link
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management option to ensure proper processing time calculation for this 2507.
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Enter Yes if the veteran requested a reschedule or 'No Showed' the appointment
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Enter No if the Clinic required a reschedule.
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Is this appointment due to a veteran requested cancellation or 'No Show'
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You have not indicated if the reschedule was due to action by the veteran.
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The new appointment will not be linked. You will need to adjust
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the link for this appointment with the AMIE/C&P appointment link management
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option to ensure proper processing time calculation for this 2507.
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Remember to cancel the appointment for
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and do NOT auto-rebook.
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Hit Return to continue
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Currently:
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You have not selected a 2507 request to link the C&P appointment to.
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The appointment should be linked with the AMIE/C&P Appointment Link
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Management Option to ensure proper processing time calculation for this 2507
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in the event of a veteran cancellation.
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You have made a C&P appointment for a patient who has no pending 2507 request!
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Adding new C&P appointment link for 2507 request dated
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Adjusting C&P appointment link for 2507 request dated
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MALIGNANCIES OR TUBERCULOSIS (GU)
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1. Disease active or inactive -
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2. If inactive, date last treatment or date determined inactive -
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3. Assess clinical findings -
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4. Assess laboratory findings -
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Narrative: NONE
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A. Medical history (note history of augmentation mammoplasty with
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prosthetic implant or reduction mammoplasty):
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1. Axillary glands removal -
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2. Size of scar -
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3. Fixation of scar -
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4. Contour of scar -
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5. Muscle loss -
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6. Tenderness of scar -
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7. Nerve damage -
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8. Presence of aching, pain or limited use of upper extremeties -
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9. Note whether active malignant process is present -
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10. If malignancy is inactive, state date of last surgical, radiation
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or chemical treatment -
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MENTAL DISORDERS
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A. Medical and occupational history
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D. Specific evaluation information required by the rating board
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E. Diagnostic tests (including psychological testing if deemed necessary):
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For MENTAL, NOT ELSEWHERE CLASSIFIED
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Type of Exam: MENTAL, NOT ELSEWHERE CLASSIFIED
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MUSCLES (ORTHOPEDIC)
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1. Tissue loss comparison -
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2. Muscles penetrated -
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3. Scar formation measurement (sensitiveness, tenderness) -
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5. Damage to tendons -
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6. Damage to bones, joints, nerves -
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8. Evidence of pain -
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9. Evidence of muscle hernia -
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MOUTH AND THROAT
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All pertinent data must be recorded in the history in order
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that the otolaryngological change discovered may be correlated
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with evidence of disease found in other systems of the
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1. Oral cavity -
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5. Pyriform fossae -
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Type of Exam: NEPHROLOGICAL
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1. Report presence or absence of calculi -
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2. If stone, presence and size if retained -
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3. Frequency of attacks of colic -
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4. Catheter drainage requirments, including frequency -
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5. Presence or absence of infection -
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6. Involvement of other kidney -
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INTESTINE (DIGESTIVE)
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in the
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portion of this examination
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is critical to the degree of disability assigned for the
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3. Is the veteran anemic? -
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6. Diarrhea and/or constipation -
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7. Bowel disturbance -
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8. Abdominal disturbance -
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NECK, ABNORMALITIES OF,
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NOT RESULT OF INJURY OR BONE DISEASE
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The report of examination should include any abnormal position
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of the head, range of motion of the head, evidence of
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paralysis of the neck muscles, and asymmetry produced by
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abnormal swelling or masses.
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1. Range of motion -
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, NOT ELSEWHERE CLASSIFIED
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1) How does the residual disability affect the earning capacity
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of the veteran in job performance?
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2) How does the residual disability affect normal everyday activities?
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3) If the disability has constant activity, are there
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any periods of remission during the year?
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4) If there are acute exacerbations, what effects are there on
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everyday life?
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Compensation and Pension Exam for
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For NEUROLOGICAL, NOT ELSEWHERE CLASSIFIED
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Type of Exam: NEUROLOGICAL, NOT ELSEWHERE CLASSIFIED
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NEPHRITIS, EXCEPT CHRONIC PYELONEPHRITIS
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2. Presence or absence of albumin casts -
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4. Red blood cells -
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5. Retention of non-protein nitrogen, creatinine or urea nitrogen -
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6. Describe overall impairment of kidney function -
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7. Report presence or absence of any cardiac complications -
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Diagnosic/clinical test results:
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NOSE AND SINUS
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Report both functional and cosmetic impairment.
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1. External nose -
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2. Nasal vestibule -
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3. Right and left nasal cavities -
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b. Floor of the nose -
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c. Inferior meatus -
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d. Inferior turbinates -
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e. The middle meati -
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f. The middle turbinate -
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g. The spheno-ethmoidal recess -
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h. The olfactory area -
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i. The superior turbinates -
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4. The paranasal sinuses-
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NOSE AND THROAT
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Describe the location and nature of the injury or disease
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with particular attention to the interference with speech,
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sense of smell, and/or breathing space. If all or part of the
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nose is missing provide
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photographs. Localize manifestations
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of chronic sinusitis, if present.
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1. Interference with breathing space -
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2. Headaches, severity, and frequency -
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3. Purulent discharge -
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4. Frequency of allergic attacks, baseline status in between -
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2507 Exams Not Scheduled Within Three Days
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Enter STARTING DATE REPORTED TO MAS:
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and ENDING DATE REPORTED TO MAS:
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2507 Requests Not Scheduled in Three Days at
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A right margin of 132 is required for this output!
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2507 exams not scheduled in 3 days
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SDATE*
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HD*
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Total requests:
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patient file record missing
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Date reported-MAS
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Date scheduled
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Requested by
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For NEPHROLOGICAL, NOT ELSEWHERE CLASSIFIED
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Type of Exam: NEPHROLOGICAL, NOT ELSEWHERE CLASSIFIED
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For ORGANS OF SENSE, NOT ELSEWHERE CLASSIFIED
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Type of Exam: ORGANS OF SENSE, NOT ELSEWHERE CLASSIFIED
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Additional Veteran Information
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Is this the correct Veteran
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Enter Y if it is the correct Veteran, N to reselect
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Edit Veteran Data
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Want to edit it again
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Enter Y to edit the information again or N to skip.
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1,5,0,2,0^...Error, required information missing!....
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0,7,0,1:2,0^...Unable to complete, Request aborted!.....
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DVBA C NEW C&P VETERAN
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PULMONARY TUBERCULOSIS AND MYCOBACTERIAL DISEASES
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Is pulmonary tuberculosis or other mycobacterial disease
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active? If so, identify the organism. In reactivated
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cases, it is necessary to know whether this is reactivation
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of the old disease or a separate and distinct new infection.
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1. IN ALL CASES:
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a. Date of inactivity -
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b. Extent of structural damage to lungs -
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c. Provide pulmonary function studies -
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2. In PENSION CASES ONLY:
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a. Disease condition after six months of treatment -
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b. Disease condition after twelve months of treatment -
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Additional note to the physician:
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In all claims, if the disease is inactive and if the inactivity was confirmed
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at a non-VA facility, obtain the name and mailing address of the facility
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from the veteran so that the
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Regional Office may request the report.
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For PULMONARY, NOT ELSEWHERE CLASSIFIED
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Type of Exam: PULMONARY, NOT ELSEWHERE CLASSIFIED
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NON-TUBERCULOUS DISEASES AND INJURIES OF THE RESPIRATORY SYSTEM
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1. State if active malignant process is present. If so, nothing
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further is needed -
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2. If malignancy is inactive, report date/place of last
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surgery, radiation or chemical therapy -
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3. For non-malignant diseases, injuries, residuals of inactive or
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cured malignancies -
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a. Report structural changes to the lungs -
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b. Provide pulmonary function studies -
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c. Schedule additional special studies as necessary to evaluate
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any extra-pulmonary manifestations that may be detected -
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d. State whether the disease is in remission or demonstrably
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LOSS OF PENIS, ALL OR PARTIAL; IMPOTENCE (GU)
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A complete and detailed examination of the entire
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genitourinary system is needed with close correlation
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between this, the history and laboratory studies.
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Any penile deformity should be described in detail.
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1. Extent of loss -
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2. Erectile power preserved -
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3. If impotent, state cause -
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4. State whether impotence is permanent or if erectile power
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can be restored -
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5. Describe any penile deformity in detail -
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Press RETURN
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No pending requests found for selected parameters.
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Pending 2507 Request Report
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Do you want to sort by:
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(A)ge of request
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(V)eteran name
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(R)outing location
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Selection: V//
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Answer must be A, S, V, or R.
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eteran name
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ge of request
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outing location
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Status selection:
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Select STATUS (enter A for all): P//
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Status must be N (new), P (pending), T (transcribed) or A (all)
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Age selection:
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Enter EARLIEST age:
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Enter the shortest time span (in days) which 2507 processing has elapsed.
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Cannot be less than one day !
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If you want NEW requests (zero days), sort by status.
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and OLDEST age:
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Enter the longest time span (in days) which 2507 processing has elapsed.
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Cannot be less than 1 day
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Earliest age must be less than oldest age
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Routing Location Selection:
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Enter MEDICAL CENTER DIVISION:
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Do you want elapsed time reported
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in (C)alender days or (W)ork days? C//
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Must be C for Calendar, W for Workdays
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or simply press RETURN to accept the default.
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Calendar
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(Elapsed time in
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Work
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2507 PENDING REPORT
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THE PERIPHERAL NERVES
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Narrative: None
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Examining provider:
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Examined on:
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Examination results:
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This exam was CANCELLED by
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the RO.
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MAS.
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Exam Results Continued
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Processing time:
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AGENT ORANGE
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Last rating exam date:
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Priority of exam:
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Site name not in file
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Continued on next page
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VA Form 2507
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This exam has been reviewed and approved by the examining provider
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and signed by the veteran
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Approved by: ___________________________________ Date: _____________
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Provider signature: ___________________________________ Date: _____________
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You DIVISION NUMBER is incorrect.
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Your DIVISION NUMBER is invalid.
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C & P Exam Printing
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Note: All reports will be produced in 'terminal-digit' order.
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2507 Final Exam Report
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Nothing to print
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Total requests to be printed:
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Final C&P Reports for print date
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Operator:
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Too many locations to store! Some locations may not be reported.
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A bad 'D' X-Reference exists on the 2507 Request File (#396.3) for
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Please notify IRM at the facility where you have created
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this report.
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POST-TRAUMATIC STRESS DISORDER
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A. Medical and occupational history:
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1. Immediate pre-military events and details of training -
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2. Events in the war zone -
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3. Post-active service events (to present) -
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4. Employment history prior to and following
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active service -
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B. Subjective complaints (include the veteran's history of unusually
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traumatic stressors)
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1) Describe the duration of the disturbance from the symptoms shown above.
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Attachment A for Post-Traumatic Stress Disorder
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DSM-III-R Diagnostic Criteria for PTSD
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PITUITARY TUMORS - ACROMEGALY, PROLACTINOMA
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1. Frequency of headaches -
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2. Changes in vision -
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3. Cardiac symptoms -
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4. Joint pain -
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6. Kyphosis of cervicodorsal spine -
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7. Abnormal glucose tolerance -
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8. Genital atrophy -
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lumps or masses
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diabetes mellitus
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thyroid disorders
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b. Head, eye, ear, nose and throat
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eye pain
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Ears:
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hearing loss
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external ear
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Nose:
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Mouth-throat:
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bleeding gums
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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