source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWEM1.m@ 628

DVBCWEM1 ;ALB/CMM ENDOCRINE MISC. DISEASES WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;     Comment on:
 ;;     1.  Date of diagnosis and how established.
 ;;
 ;;
 ;;     2.  Fatigability.
 ;;
 ;;
 ;;     3.  Headaches.
 ;;
 ;;
 ;;     4.  Changes in vision.
 ;;
 ;;
 ;;     5.  Neurologic, cardiovascular, or gastrointestinal symptoms.
 ;;
 ;;
 ;;     6.  Treatments (surgery, medications, hormones), including dose,
 ;;         frequency, response, side effects.  For malignancy, provide 
 ;;         date of completion of treatment for malignancy.
 ;;
 ;;
 ;;     7.  Weight gain or loss.
 ;;
 ;;
 ;;     8.  Excessive thirst, frequency of urination.  
 ;;
 ;;
 ;;     9.  Describe the effects of the condition(s) 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.  For hypoparathyroidism, thyroid surgery scar?
 ;;
 ;;
 ;;    2.  For diabetes insipidus, signs of dehydration?
 ;;
 ;;
 ;;    3.  For Addison's disease, muscle strength, blood pressure, skin 
 ;;        pigmentary changes.  Number of crises (with peripheral vascular 
 ;;        collapse) or episodes (less acute and severe than crisis - no
 ;;        peripheral vascular collapse).
 ;;
 ;;
 ;;    4.  For pluriglandular syndromes, see examinations for glands affected.
 ;;
 ;;
 ;;    5.  Describe all residuals of benign or malignant neoplasm, 
 ;;        including those related to treatment.
 ;;
 ;;
 ;;    6.  Is the disease active or in remission?
 ;;
 ;;
 ;;    7.  For hyperparathyroidism, history of kidney stones.  History 
 ;;        demineralization of skeleton.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    Provide, as appropriate/as needed to establish diagnosis:
 ;;    1.  Blood and urinary calcium.
 ;;    2.  X-ray of bones to confirm decalcification.
 ;;    3.  Glucose tolerance test, if necessary.
 ;;    4.  Antidiuretic hormone level.
 ;;    5.  Serum and urine electrolytes.
 ;;    6.  Urine specific gravity.
 ;;    7.  Serum cortisol.
 ;;    8.  Serum creatinine.
 ;;    9.  Serum glucose.
 ;;   10.  ACTH test.
 ;;   11.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END