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1DVBCWHD1 ;ALB/CMM HEMIC DISORDERS WKS TEXT ; 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. Frequency and duration of crisis if sickle cell disease.
14 ;;
15 ;;
16 ;; 2. Fatigability and/or weakness? (Is light manual labor precluded?)
17 ;;
18 ;;
19 ;; 3. Headaches?
20 ;;
21 ;;
22 ;; 4. History of infections? If yes, frequency and response to therapy?
23 ;;
24 ;;
25 ;; 5. Shortness of breath? If yes, with what degree of exertion?
26 ;;
27 ;;
28 ;; 6. Chest pain? Symptoms of claudication?
29 ;;
30 ;;
31 ;; 7. History and frequency of transfusions, phlebotomy, bone marrow
32 ;; transplant, myelo-suppressant therapy.
33 ;;
34 ;;
35 ;; 8. Symptoms of other end organ pathology?
36 ;;
37 ;;
38 ;; 9. Disease activity (exacerbations/remission)? If there were
39 ;; exacerbations, what was the state of the veteran's health
40 ;; between exacerbations?
41 ;;
42 ;;
43 ;; 10. Current and past treatment history including date and type of
44 ;; last treatment?
45 ;;
46 ;;
47 ;; 11. Syncope, lightheadedness.
48 ;;
49 ;;TOF
50 ;;C. Physical Examination (Objective Findings):
51 ;;
52 ;; Address each of the following as appropriate to the condition
53 ;; being examined and fully describe current findings:
54 ;; 1. Swelling of hands and/or feet (edema)?
55 ;;
56 ;;
57 ;; 2. Presence of pallor (nail beds, mucosal surfaces, and skin)?
58 ;;
59 ;;
60 ;; 3. Any other significant physical exam findings?
61 ;;
62 ;;
63 ;; 4. Residuals of bone or other vascular infarction.
64 ;;
65 ;;
66 ;; 5. Congestive heart failure?
67 ;;
68 ;;
69 ;;D. Diagnostic and Clinical Tests:
70 ;;
71 ;; 1. Hemoglobin level, platelet count, CBC.
72 ;; 2. X-rays of bones or joints as indicated.
73 ;; 3. Include results of all diagnostic and clinical tests conducted
74 ;; in the examination report.
75 ;;
76 ;;
77 ;;E. Diagnosis:
78 ;;
79 ;; 1. Is the disease active?
80 ;;
81 ;;
82 ;;Signature: Date:
83 ;;END
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