source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNM1.m@ 628

DVBCWNM1 ;ALB/CMM NEUROLOGICAL MISC. DISORDER WKS TEXT - 1 ; 6 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Onset and course - If flare-ups exist, describe precipitating
 ;;        factors, aggravating factors, alleviating factors, alleviating
 ;;        medications, frequency, severity, duration, and whether the 
 ;;        flare-ups include pain, weakness, fatigue, or functional loss.
 ;;
 ;;
 ;;    2.  Current treatment, response, side effects.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    1.  If MIGRAINE: - Obtain the history of frequency and duration of
 ;;        attacks and description of level of activity the veteran can 
 ;;        maintain during the attacks.  For example, state if the attacks
 ;;        are prostrating in nature or if ordinary activity is possible.
 ;;
 ;;
 ;;    2.  If TICS AND PARAMYOCLONUS Complex: - Ascertain the muscle 
 ;;        group(s) involved and obtain the best possible history of 
 ;;        frequency and severity of attacks.  State the effects on daily
 ;;        activities.
 ;;
 ;;
 ;;    3.  If CHOREA, CHOREIFORM DISORDERS, ETC.: - Describe manifestations 
 ;;        by impairment of strength, coordination, tremor, etc., with 
 ;;        particular attention to the effects of the performance of 
 ;;        ordinary activities of daily living.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;TOF
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END