DI 22510.024 CE Report Content Guidelines - Respiratory
A. Policy General
Specific requirements exist in addition to all general internal medicine guidelines. See DI 22510.022.
B. Policy Specific
1. General Examination
The report should note and describe:
The occurrence of cough, labored breathing, use of accessory muscles of respiration, audible wheezing, pallor, cyanosis, hoarseness, clubbing of fingers, or the presence of chest wall deformity. Respiratory rate should be observed and reported.
The diameter of the chest on inspiration and expiration, distention of neck veins and ankle edema.
Whether the expiratory phase of respiration is prolonged.
Presence or absence of adventitious sounds on auscultation of the chest.
When relevant to the disease, the employment history should be reported (e.g., pneumoconiosis or exposure to physical irritants producing respiratory symptoms.)
Characteristics - Dyspnea should be described with respect to:
Dates and mode of onset;
Influence of infection and precipitating activities;
Whether it is associated with palpitation, wheezing, chest discomfort, or hyperventilation symptoms.
Respiratory Versus Cardiac Dyspnea - Inquiry should be made to determine whether the claimant has:
A history of heart disease;
Experienced paroxysmal nocturnal dyspnea or
Associated peripheral edema, hypertension, past myocardial infarction, angina, rheumatic heart disease,
cardiac murmur, etc.
3. Episodic Disorders
The report should include details as to:
Onset and precipitating factors;
Frequency and intensity;
Mode of treatment and response;
Description of severe respiratory attack.
4. Laboratory Tests
Spirometry should be performed and reported as specified in section 3.00E. of the respiratory listings.
Diffusing Capacity of the Lungs for Carbon Monoxide should be performed and reported as specified in section 3.00F.1. of the respiratory listings.
Resting or exercise Arterial Blood Gas Studies should be performed and reported as specified in sections 3.00F.2. and 3.00F.3. and 4. of the respiratory listings.
5. Optional Tests
A chest x-ray or other appropriate imaging techniques, hematocrit, and electrocardiogram are sometimes useful in diagnosis.