source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWEM1.m@ 1046

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[613]1DVBCWEM1 ;ALB/CMM ENDOCRINE MISC. DISEASES WKS TEXT - 1 ; 5 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. Date of diagnosis and how established.
14 ;;
15 ;;
16 ;; 2. Fatigability.
17 ;;
18 ;;
19 ;; 3. Headaches.
20 ;;
21 ;;
22 ;; 4. Changes in vision.
23 ;;
24 ;;
25 ;; 5. Neurologic, cardiovascular, or gastrointestinal symptoms.
26 ;;
27 ;;
28 ;; 6. Treatments (surgery, medications, hormones), including dose,
29 ;; frequency, response, side effects. For malignancy, provide
30 ;; date of completion of treatment for malignancy.
31 ;;
32 ;;
33 ;; 7. Weight gain or loss.
34 ;;
35 ;;
36 ;; 8. Excessive thirst, frequency of urination.
37 ;;
38 ;;
39 ;; 9. Describe the effects of the condition(s) on the veteran's
40 ;; usual occupation and daily activities.
41 ;;
42 ;;
43 ;;C. Physical Examination (Objective Findings):
44 ;;
45 ;; Address each of the following and fully describe current findings:
46 ;; 1. For hypoparathyroidism, thyroid surgery scar?
47 ;;
48 ;;
49 ;; 2. For diabetes insipidus, signs of dehydration?
50 ;;
51 ;;
52 ;; 3. For Addison's disease, muscle strength, blood pressure, skin
53 ;; pigmentary changes. Number of crises (with peripheral vascular
54 ;; collapse) or episodes (less acute and severe than crisis - no
55 ;; peripheral vascular collapse).
56 ;;
57 ;;
58 ;; 4. For pluriglandular syndromes, see examinations for glands affected.
59 ;;
60 ;;
61 ;; 5. Describe all residuals of benign or malignant neoplasm,
62 ;; including those related to treatment.
63 ;;
64 ;;
65 ;; 6. Is the disease active or in remission?
66 ;;
67 ;;
68 ;; 7. For hyperparathyroidism, history of kidney stones. History
69 ;; demineralization of skeleton.
70 ;;
71 ;;
72 ;;D. Diagnostic and Clinical Tests:
73 ;;
74 ;; Provide, as appropriate/as needed to establish diagnosis:
75 ;; 1. Blood and urinary calcium.
76 ;; 2. X-ray of bones to confirm decalcification.
77 ;; 3. Glucose tolerance test, if necessary.
78 ;; 4. Antidiuretic hormone level.
79 ;; 5. Serum and urine electrolytes.
80 ;; 6. Urine specific gravity.
81 ;; 7. Serum cortisol.
82 ;; 8. Serum creatinine.
83 ;; 9. Serum glucose.
84 ;; 10. ACTH test.
85 ;; 11. Include results of all diagnostic and clinical tests conducted
86 ;; in the examination report.
87 ;;
88 ;;
89 ;;
90 ;;E. Diagnosis:
91 ;;
92 ;;
93 ;;Signature: Date:
94 ;;END
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