source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWNM1.m@ 1742

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1DVBCWNM1 ;ALB/CMM NEUROLOGICAL MISC. DISORDER WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Onset and course - If flare-ups exist, describe precipitating
14 ;; factors, aggravating factors, alleviating factors, alleviating
15 ;; medications, frequency, severity, duration, and whether the
16 ;; flare-ups include pain, weakness, fatigue, or functional loss.
17 ;;
18 ;;
19 ;; 2. Current treatment, response, side effects.
20 ;;
21 ;;
22 ;;C. Physical Examination (Objective Findings):
23 ;;
24 ;; 1. If MIGRAINE: - Obtain the history of frequency and duration of
25 ;; attacks and description of level of activity the veteran can
26 ;; maintain during the attacks. For example, state if the attacks
27 ;; are prostrating in nature or if ordinary activity is possible.
28 ;;
29 ;;
30 ;; 2. If TICS AND PARAMYOCLONUS Complex: - Ascertain the muscle
31 ;; group(s) involved and obtain the best possible history of
32 ;; frequency and severity of attacks. State the effects on daily
33 ;; activities.
34 ;;
35 ;;
36 ;; 3. If CHOREA, CHOREIFORM DISORDERS, ETC.: - Describe manifestations
37 ;; by impairment of strength, coordination, tremor, etc., with
38 ;; particular attention to the effects of the performance of
39 ;; ordinary activities of daily living.
40 ;;
41 ;;
42 ;;D. Diagnostic and Clinical Tests:
43 ;;
44 ;; 1. Include results of all diagnostic and clinical tests conducted
45 ;; in the examination report.
46 ;;
47 ;;TOF
48 ;;E. Diagnosis:
49 ;;
50 ;;
51 ;;Signature: Date:
52 ;;END
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