Arrhythmias

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

1. Type of arrhythmia, onset of disorder, frequency and duration of attacks. Attacks confirmed by EKG or Holter monitor?.
2. Pacemaker present? If so, when was it inserted, effectiveness, side effects?
3. Other treatment? If so, type, effectiveness, side effects?
4. For sustained ventricular arrhythmias, atrioventricular block, and implantable cardiac pacemakers (if ventricular arrhythmia or atrioventricular block was the reason for the pacemaker), the examiner must provide the METs level, determined by exercise testing, at which symptoms of dyspnea, fatigue, angina, dizziness, or syncope result.
4. Exercise testing is not required for the above listed conditions in the following circumstances:

a. If exercise testing is medically contraindicated:

1. In that case, provide the medical reason exercise testing cannot be conducted, and
2. 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.

2. For sustained ventricular arrhythmia—from date of hospital admission for initial evaluation and medical therapy for a sustained ventricular arrhythmia or for ventricular aneurysmectomy, and for six months following discharge.
3. With an automatic implantable Cardioverter-Defibrillator (AICD) in place.
1. For two months following hospital admission for implantation or reimplantation of an implantable cardiac pacemaker.
2. 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.

6. For implantable cardiac pacemakers—if supraventricular arrhythmia was the reason for the pacemaker—describe any attacks of atrial fibrillation or other symptoms.
7. Describe the effects of the condition on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Heart size and method of determination, heart rate and rhythm, blood pressure.
2. Status of cardiac function - evidence of congestive heart failure.
3. Cardiac arrhythmia - type. Confirmed by EKG or Holter monitor?

D. Diagnostic and Clinical Tests:

1. EKG.
2. Holter monitor, other tests as indicated.
3. Chest X-ray, exercise stress test, echocardiogram, Holter monitor, thallium study, angiography, etc., as appropriate, and as required or indicated.
4. Include results of all diagnostic and clinical tests conducted in the examination report, including status of left ventricular function, if measured.

E. Diagnosis:

Signature:

Date: