source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWHI3.m@ 1806

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1DVBCWHI3 ;ALB/RLC HIV-RELATED ILLNESS WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment On:
11 ;;
12 ;; 1. Recurrent opportunistic infections - type.
13 ;; 2. Constitutional symptoms - recurrent, refractory, any currently present.
14 ;; 3. Diarrhea.
15 ;; 4. Debility.
16 ;; 5. Progressive weight loss.
17 ;; 6. Other symptoms - lymphadenopathy, fever, cough, dyspnea, headaches,
18 ;; difficult or painful swallowing, vision loss, etc.
19 ;; 7. Periods of remissions in symptomatology - frequency, average duration,
20 ;; date of last remission.
21 ;; 8. Depression or memory loss.
22 ;; 9. Treatment, type duration, response, side effects. Is this an approved
23 ;; medication?
24 ;; 10. Describe the effects of the condition on the veteran's usual
25 ;; occupation and daily activities.
26 ;; 11. History of hospitalizations or surgery, reason or type of surgery,
27 ;; dates and location, if known.
28 ;; 12. History of malignant neoplasm.
29 ;;
30 ;; a. Date of diagnosis.
31 ;; b. Diagnosis.
32 ;; c. Type of treatment, dates.
33 ;; d. Last date of treatment.
34 ;;
35 ;;C. Physical Examination (Objective Findings):
36 ;;
37 ;; Address each of the following and fully describe, follow additional
38 ;; worksheets as appropriate:
39 ;;
40 ;; 1. Secondary diseases affecting multiple body systems. Describe.
41 ;; 2. HIV-related illnesses. Describe.
42 ;; 3. Neoplasm related to HIV-related illness. Describe.
43 ;; 4. T4 cell counts.
44 ;; 5. Hairy cell leukoplakia.
45 ;; 6. Oral candidiasis.
46 ;; 7. Side effects from the use of HIV-related medications. Describe.
47 ;; 8. Lymphadenopathy.
48 ;; 9. Hepatomegaly.
49 ;; 10. Splenomegaly.
50 ;; 11. If evidence of memory loss or depression (refer for examination by
51 ;; mental health provider).
52 ;;
53 ;;D. Diagnostic and Clinical Tests:
54 ;;
55 ;; Provide:
56 ;;
57 ;; 1. T4 Cell counts.
58 ;; 2. Include results of all diagnostic and clinical tests conducted
59 ;; in the examination report.
60 ;;
61 ;;
62 ;;E. Diagnosis:
63 ;;
64 ;; 1. Definitive diagnosis of AIDS. (Use CDC Definition).
65 ;; 2. Active opportunistic infection or neoplasm.
66 ;;
67 ;;
68 ;;
69 ;;Signature: Date:
70 ;;END
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