source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWVN1.m

Last change on this file was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version

File size: 5.6 KB
Line 
1DVBCWVN1 ;ALB/JFP ARTERIES, VEINS AND MISCELLANEOUS WKS TEXT - 1 ; 11 FEB 1998
2 ;;2.7;AMIE;**16**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;; For all conditions, comment on:
10 ;; 1. Course, including onset of disorder, and any treatment,
11 ;; including surgery (type and when carried out).
12 ;; 2. Symptoms.
13 ;; 3. Is exercise and exertion precluded by the condition?
14 ;; 4. Current treatment - type, effectiveness, side effects.
15 ;; 5. If surgery has been done, report effectiveness and any
16 ;; residual or recurrent symptoms.
17 ;; 6. Describe the effects of the condition on the veteran's usual
18 ;; occupation and daily activities.
19 ;;
20 ;; For aortic aneurysm, aneurysm of any large artery, aneurysm of any
21 ;; small artery, arteriovenous fistula, arteriosclerosis obliterans
22 ;; and thromboangiitis obliterans, additionally comment on:
23 ;; 1. If lower extremities are affected, is there claudication,
24 ;; and, if so, after how many yards of walking on level ground
25 ;; at 2 miles per hour does it develop?
26 ;; 2. Is there pain at rest?
27 ;;
28 ;; For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia,
29 ;; additionally comment on:
30 ;; 1. Describe a characteristic attack.
31 ;; 2. Record the frequency, duration, and severity of
32 ;; characteristic attacks.
33 ;; 3. Describe which parts of the body are affected. For
34 ;; angioneurotic edema, state whether laryngeal edema occurs
35 ;; and how frequently.
36 ;; 4. What is the current treatment - type, dose, effectiveness,
37 ;; side effects?
38 ;; 5. Describe the effects of the condition on the veteran's usual
39 ;; occupation and daily activities.
40 ;;
41 ;; For Varicose veins and Post-phlebitic syndrome of any etiology,
42 ;; additionally comment on:
43 ;; 1. Describe symptoms, noting particularly whether aching,
44 ;; fatigue or abnormal sensations are present in the leg at
45 ;; rest or after prolonged standing or walking.
46 ;; 2. Are symptoms or edema relieved by elevation of the extremity
47 ;; compression hosiery, or other measures?
48 ;; 3. What is the current treatment - type, dose, effectiveness,
49 ;; side effects.
50 ;; 4. What are the effects of the condition on the veteran's usual
51 ;; occupation and daily activities?
52 ;;
53 ;; For soft tissue sarcoma or other malignant neoplasms of vascular
54 ;; origin:
55 ;; 1. Record date of diagnosis and pathologic diagnosis.
56 ;; 2. Record type and dates of treatment. If treatment has been
57 ;; completed, state date of last treatment.
58 ;; 3. Describe current symptoms. If treatment has been completed
59 ;; describe residual or recurrent symptoms.
60 ;; 4. What are the effects of the condition on the veteran's
61 ;; usual occupation and daily activities?
62 ;;
63 ;;C. Physical Examination (Objective Findings):
64 ;; 1. For aortic aneurysm, aneurysm of any large artery, aneurysm
65 ;; of any small artery, or arteriovenous fistula:
66 ;; a. State size of aneurysm, cardiac status, including
67 ;; heart size and rate, pulse pressure, and whether there
68 ;; is evidence of high output failure.
69 ;; b. If extremities are affected, describe temperature and
70 ;; color, pulses, trophic changes, ulcers (deep or
71 ;; superficial?), edema, dermatitis, cellulitis.
72 ;; c. If lower extremities are affected, record
73 ;; ankle/brachial index (using Doppler).
74 ;; d. If surgery has been carried out, describe residual
75 ;; findings, using appropriate worksheet for the affected
76 ;; body system or organ.
77 ;; 2. For arteriosclerosis obliterans and thromboangiitis
78 ;; obliterans:
79 ;; a. Describe each affected extremity separately.
80 ;; b. Record ankle/brachial index (using Doppler).
81 ;; c. Describe temperature and color of extremities, pulses,
82 ;; trophic changes, ulcers (deep or superficial?).
83 ;; d. If surgery has been carried out, describe any
84 ;; residuals or side effects of surgery.
85 ;; 3. For Raynaud's phenomenon, angioneurotic edema, and
86 ;; erythromelalgia:
87 ;; a. Describe ulcers, autoamputations, and any other
88 ;; current findings.
89 ;; 4. For Varicose veins and Post-phlebitic syndrome of any
90 ;; etiology:
91 ;; a. Describe any visible or palpable varicose veins.
92 ;; b. Describe extent of any ulcers, edema, stasis
93 ;; pigmentation, and eczema. If edema is present, is it
94 ;; boardlike? Is it persistent?
95 ;; c. Describe each affected extremity separately.
96 ;; 5. For soft tissue sarcoma or other malignant neoplasms of
97 ;; vascular origin:
98 ;; a. Describe all current findings, whether pre- or
99 ;; post-treatment, including any residuals of treatment.
100 ;; Use other worksheets, if necessary, specific to the
101 ;; affected body system or organs.
102 ;;
103 ;;D. Diagnostic and Clinical Tests:
104 ;; 1. X-rays, Doppler vascular studies, angiogram, etc., as
105 ;; appropriate, and if indicated.
106 ;; 2. Include results of all diagnostic and clinical tests
107 ;; conducted in the examination report.
108 ;;
109 ;;E. Diagnosis:
110 ;;
111 ;;
112 ;;Signature: Date:
113 ;;END
Note: See TracBrowser for help on using the repository browser.