source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWSC1.m@ 1154

DVBCWSC1 ;ALB/CMM INFEC, IMM, NUTRITIONSL DIS WKS TEXT - 1 ; 6 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;Narrative:  Many infectious diseases, immune disorders, and
 ;;nutritional deficiencies have acute phases at onset and 
 ;;accompanying recurrences but leave little or no residual 
 ;;disability beyond the acute phase.  Other such conditions may 
 ;;present with slow progression and show significant residual 
 ;;disability.  The examiner must diligently search for residual 
 ;;disabilities upon which adjudication of the case may be made.
 ;;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Date of symptom onset.
 ;;
 ;;
 ;;    2.  Date of diagnosis.
 ;;
 ;;
 ;;    3.  Clinical manifestations.
 ;;
 ;;
 ;;    4.  Treatment (type, frequency, duration, response, side effects).
 ;;
 ;;
 ;;    5.  Disease activity (exacerbations and/or remissions)?  If there
 ;;        were exacerbations, what was the state of the veteran's health
 ;;        between exacerbations?  Frequency and duration of exacerbations.
 ;;
 ;;
 ;;    6.  Current symptoms.
 ;;
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Is the condition still present?
 ;;
 ;;
 ;;    2.  Current weight, nutrition.  Any residuals of malnutrition, 
 ;;        vitamin deficiency?
 ;;
 ;;
 ;;    3.  General appearance.
 ;;
 ;;
 ;;    4.  Describe findings of all organ systems involved.  See 
 ;;        appropriate examination worksheets - respiratory, joints, 
 ;;        cardiovascular, etc.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    1.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;    NOTE:  If an infectious etiology is documented, specify the organism.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END