source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWSD1.m@ 1389

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1DVBCWSD1 ;ALB/CMM SKIN DISEASES (Other Than Scars) 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 of disease and course - intermittent, constant.
14 ;;
15 ;;
16 ;; 2. Current treatment - include side effects.
17 ;;
18 ;;
19 ;; 3. Symptoms - pruritus, pain, etc.
20 ;;
21 ;;
22 ;;C. Physical Examination (Objective Findings):
23 ;;
24 ;; Address each of the following and fully describe current findings:
25 ;; 1. Extent of disease - specify what exposed areas are involved
26 ;; and how large they are.
27 ;;
28 ;;
29 ;; 2. Ulceration, exfoliation, or crusting.
30 ;;
31 ;;
32 ;; 3. Associated systemic or nervous manifestations.
33 ;;
34 ;;
35 ;;D. Diagnostic and Clinical Tests:
36 ;;
37 ;;
38 ;; 1. Biopsy, scrapings if indicated.
39 ;; 2. Include results of all diagnostic and clinical tests conducted
40 ;; in the examination report.
41 ;;
42 ;;
43 ;;E. Diagnosis:
44 ;;
45 ;; 1. Take COLOR PHOTOGRAPHS if disfigurement or disfiguring scars
46 ;; are present.
47 ;;
48 ;;
49 ;;Signature: Date:
50 ;;END
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