Disability Examination Worksheets
Heart
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A. Review of Medical Records: B.
Medical History (Subjective Complaints):
Comment on:
- Past history - describe onset of disorder and frequency of
cardiac symptoms, including angina, dyspnea, fatigue, dizziness, and syncope.
Record dates and severity of episodes of acute cardiac illness, including
myocardial infarction, congestive heart failure, and acute rheumatic heart
disease. Describe all cardiac surgery, including coronary artery bypass,
valvular surgery, cardiac transplant, and angioplasty.
- Current treatment - type, dosage, response, and side
effects.
- With the exceptions given below, examinations for valvular heart
disease, endocarditis, pericarditis, pericardial adhesions, syphilitic heart
disease,, arteriosclerotic heart disease, myocardial infarction, hypertensive
heart disease, heart valve replacement, coronary bypass surgery, cardiac
transplantation, and cardiomyopathy, require the examiner to provide the
METs level, determined by exercise testing, at which symptoms of dyspnea,
fatigue, angina, dizziness, or syncope result.
- Exercise testing is not required for the above
listed conditions in the following circumstances:
a. If exercise testing is medically
contraindicated:
- In that case, provide the medical reason exercise testing
cannot be conducted, and
- Provide an estimate of the level of activity
(expressed in METs and supported by specific examples, such as slow stair
climbing, or shoveling snow) that results in dyspnea, fatigue, angina,
dizziness, or syncope.
- If left ventricular dysfunction is present, and the ejection
fraction is 50 percent or less.
- If there is chronic congestive heart failure or there has been
more than one episode of acute congestive heart failure in the past year.
- With valvular heart disease - during active infection
with valvular heart damage and for three months following cessation of therapy
for the active infection.
- With endocarditis - for three months following cessation of
therapy for active infection with cardiac involvement.
- With pericarditis - for three months following cessation of
therapy for active infection with cardiac involvement.
- With myocardial infarction - for three months following
myocardial infarction.
- With valve replacement - for six months following date of
hospital admission for valve replacement.
- With coronary bypass surgery - for three months following
hospital admission for surgery.
- For cardiac transplantation - for indefinite period from date
of hospital admission for cardiac transplantation.
- If an exercise test has been done within the past year, the
results are of record, and there is no indication that there has been a change
in the cardiac status of the veteran since.
- For hyperthyroid heart disease, if atrial fibrillation is
present, use arrhythmia worksheet. Also use endocrine worksheet if examining
for hyperthyroidism.
- Describe the effects of the condition on the veteran's
usual occupation and daily activities.
- Even when special examinations and tests (e.g.,
exercise testing) are not required under the worksheet guidelines, they
may be requested or conducted at the discretion of the examiner, when the
examiner believes that the available information does not fully reflect the
severity of the veterans cardiovascular disability.
C. Physical Examination (Objective Findings):
Address each of the following and fully describe current
findings:
- Heart size and method of determination, heart rhythm and rate,
heart sounds, blood pressure.
- Evidence of congestive heart failure - rales, edema,
liver enlargement, etc.
D. Diagnostic and Clinical Tests:
- Chest X-ray, EKG, exercise stress test, echocardiogram, Holter
monitor, thallium study, angiography, etc., as appropriate, and as required or
indicated.
- Include results of all diagnostic and clinical tests conducted in
the examination report, including status of left ventricular function, if
measured.
- Valvular heart disease and endocarditis require documentation of
diagnosis by physical findings and either echocardiogram, Doppler
echocardiogram, or cardiac catheterization, if not already of record.
- Other types of heart disease must be documented by appropriate
objective diagnostic tests.
E. Diagnosis and Opinion:
- Type of heart disease and etiology, if known.
- Type of surgery, if any, and results.
- If the veteran is service-connected for rheumatic heart
disease and later develops non-service-connected arteriosclerotic heart
disease, state, if possible, which cardiac findings can be attributed to each
condition. If it is not possible to separate the signs and symptoms of one from
the other, so state, and explain.
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Date: |
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Reviewed/Updated Date:
April 30, 2007
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