source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWHD1.m@ 635

DVBCWHD1 ;ALB/CMM HEMIC DISORDERS WKS TEXT ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records: 
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 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Frequency and duration of crisis if sickle cell disease.
 ;;
 ;;
 ;;    2.  Fatigability and/or weakness?  (Is light manual labor precluded?)
 ;;
 ;;
 ;;    3.  Headaches?
 ;;
 ;;
 ;;    4.  History of infections?  If yes, frequency and response to therapy?
 ;;
 ;;
 ;;    5.  Shortness of breath?  If yes, with what degree of exertion?
 ;;
 ;;
 ;;    6.  Chest pain?  Symptoms of claudication?
 ;;
 ;;
 ;;    7.  History and frequency of transfusions, phlebotomy, bone marrow
 ;;        transplant, myelo-suppressant therapy.
 ;;
 ;;
 ;;    8.  Symptoms of other end organ pathology?
 ;;
 ;;
 ;;    9.  Disease activity (exacerbations/remission)?  If there were 
 ;;        exacerbations, what was the state of the veteran's health 
 ;;        between exacerbations?
 ;;
 ;;
 ;;   10.  Current and past treatment history including date and type of
 ;;        last treatment?
 ;;
 ;;
 ;;   11.  Syncope, lightheadedness.
 ;;
 ;;TOF
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following as appropriate to the condition 
 ;;    being examined and fully describe current findings:
 ;;    1.  Swelling of hands and/or feet (edema)?
 ;;
 ;;
 ;;    2.  Presence of pallor (nail beds, mucosal surfaces, and skin)?
 ;;
 ;;
 ;;    3.  Any other significant physical exam findings?
 ;;
 ;;
 ;;    4.  Residuals of bone or other vascular infarction.
 ;;
 ;;
 ;;    5.  Congestive heart failure?
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Hemoglobin level, platelet count, CBC.
 ;;    2.  X-rays of bones or joints as indicated.
 ;;    3.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;    1.  Is the disease active?
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END