1 | DVBCWDI1 ;ALB/CMM DIABETES MELLITUS WKS TEXT - 1 ; 5 MARCH 1997
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2 | ;;2.7;AMIE;**12**;Apr 10, 1995
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3 | ;
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4 | ;
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5 | TXT ;
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6 | ;;A. Review of Medical Records:
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7 | ;;
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8 | ;;
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9 | ;;
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10 | ;;B. Medical History (Subjective Complaints):
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11 | ;;
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12 | ;; Comment on:
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13 | ;; 1. Age of onset.
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14 | ;;
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15 | ;;
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16 | ;; 2. Frequency of ketoacidosis or hypoglycemic reactions
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17 | ;; (hospitalization required?).
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18 | ;;
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19 | ;;
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20 | ;; 3. Restricted diet, weight loss or gain since last exam.
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21 | ;;
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22 | ;;
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23 | ;; 4. Describe any restriction of activities.
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24 | ;;
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25 | ;;
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26 | ;; 5. Visual problems.
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27 | ;;
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28 | ;;
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29 | ;; 6. Vascular or cardiac symptoms.
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30 | ;;
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31 | ;;
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32 | ;; 7. Neurologic symptoms.
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33 | ;;
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34 | ;;
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35 | ;; 8. Treatment - oral hypoglycemic, insulin (frequency of injections).
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36 | ;;
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37 | ;;
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38 | ;; 9. Frequency of visits to diabetic care provider.
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39 | ;;
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40 | ;;
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41 | ;; 10. Other symptoms, such as anal pruritus, loss of strength.
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42 | ;;
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43 | ;;
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44 | ;;C. Physical Examination (Objective Findings):
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45 | ;;
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46 | ;; Address each of the following and fully describe current findings:
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47 | ;; 1. Blood pressure, other cardiovascular findings, including
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48 | ;; status of peripheral vessels.
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49 | ;;
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50 | ;;
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51 | ;; 2. Neurologic examination.
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52 | ;;
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53 | ;;
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54 | ;; 3. Eye examination.
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55 | ;;
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56 | ;;
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57 | ;; 4. Skin examination.
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58 | ;;
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59 | ;;
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60 | ;; 5. Examination of extremities, including feet.
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61 | ;;
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62 | ;;
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63 | ;; 6. State if the veteran has bladder or bowel functional impairment.
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64 | ;; If present, state whether partial or total, intermittent or
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65 | ;; constant, and what measures are taken as a result of the impairment.
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66 | ;;
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67 | ;;
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68 | ;;D. Diagnostic and Clinical Tests:
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69 | ;;
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70 | ;; Provide to establish diagnosis (Previously done test results should
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71 | ;; be given to establish diagnosis.):
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72 | ;; 1. Renal function tests, including 24 hour urine test for protein
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73 | ;; if renal involvement is uncertain.
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74 | ;; 2. Blood sugar.
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75 | ;; 3. Urinalysis.
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76 | ;; 4. Glucose tolerance test, if necessary to establish the diagnosis.
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77 | ;; 5. Include results of all diagnostic and clinical tests conducted
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78 | ;; in the examination report.
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79 | ;;
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80 | ;;
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81 | ;;E. Diagnosis:
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82 | ;;
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83 | ;; Comment on:
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84 | ;; 1. All complications noted - visual, cardiac, vascular, nephrologic,
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85 | ;; neurologic (including both peripheral neuropathy and cerebral
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86 | ;; effects), amputations. See examination worksheets for the
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87 | ;; conditions found.
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88 | ;;
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89 | ;;
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90 | ;;Signature: Date:
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91 | ;;END
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