source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWLY3.m@ 1361

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[613]1DVBCWLY3 ;ALB/RLC LYMPHATIC DISORDERS WKS TEXT - 1 ; 12 FEB 2007
2 ;;2.7;AMIE;**121**;Apr 10, 1995;Build 9
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;;
10 ;; Comment on:
11 ;;
12 ;; 1. If there are exacerbations/remissions, what is the state of the
13 ;; veteran's health, during remissions?
14 ;; 2. Current and past treatment history including date and type of
15 ;; last treatment, response, side effects.
16 ;; 3. If malignant neoplasm need diagnosis, date of diagnosis, dates of
17 ;; treatment, or if treatment ended, date of last treatment.
18 ;; 4. Current symptoms - lymphadenopathy, bleeding tendency, gastrointestinal
19 ;; symptoms, constitutional symptoms.
20 ;; 5. History of hospitalizations or surgery, reason or type of surgery,
21 ;; location and dates, if known.
22 ;; 6. Effects of condition on occupational functioning and daily activities.
23 ;;
24 ;;C. Physical Examination (Objective Findings):
25 ;;
26 ;; Describe the residuals of each body system affected and follow additional
27 ;; worksheets as appropriate. Comment on the following:
28 ;;
29 ;; 1. Lymphadenopathy.
30 ;; 2. Splenomegaly.
31 ;; 3. Hepatomegaly, jaundice.
32 ;; 4. Signs of bleeding.
33 ;; 5. Signs of anemia - Presence of Pallor (nail beds, mucosal surfaces and
34 ;; skin), tachycardia, systolic murmur.
35 ;; 6. Evidence of superior vena cava syndrome.
36 ;;
37 ;;D. Diagnostic and Clinical Tests:
38 ;;
39 ;; 1. Include results of all diagnostic and clinical tests conducted in
40 ;; the examination report.
41 ;;
42 ;;E. Diagnosis:
43 ;;
44 ;; 1. Is the disease active?
45 ;;
46 ;;
47 ;;
48 ;;Signature: Date:
49 ;;END
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