Respiratory (Obstructive, Restrictive, and Interstitial)

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

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Productive cough, sputum, hemoptysis, and/or anorexia.
2. Extent of dyspnea on exertion.
3. If veteran is asthmatic, report frequency of attacks and baseline functional status between attacks.
4. Treatment (type, frequency and duration including a need for oxygen), response, side effects.
5. Describe frequency and duration of any periods of incapacitation (defined as requiring bedrest and treatment by a physician).

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings:

1. Presence of cor pulmonale, RVH or pulmonary hypertension.
2. Weight loss or gain.
3. For restrictive disease, describe condition underlying restrictive disease, e.g., kyphoscoliosis, pectus excavatum, etc., unless already of record.

D. Diagnostic and Clinical Tests:

Provide:

1. Pulmonary Function Tests (unless carried out within past six months and the report is either in the claims folder or will be attached to this examination report, e.g., PFT's were in VAMC records at your facility). Spirometric pulmonary function testing should include FVC, FEV-1, and the FEV-1/FVC ratio. Both pre- and post-bronchodilatation 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.

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, since it is not useful in all situations. 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 a BVA remand in which the DLCO is requested, the DLCO MUST be done unless there is a medical contraindication.

2. Chest X-ray (if no recent results available).
3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis: