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[613]1DVBCWSD3 ;ALB/CMM SKIN DISEASES (Other Than Scars) WKS TEXT - 1 ; 11/20/02 4:43pm
2 ;;2.7;AMIE;**49**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; 1. Describe onset and course of disease, whether it is
13 ;; intermittent or constant, and whether it is progressive.
14 ;;
15 ;;
16 ;; 2. Describe current treatment. Specify the medication(s)
17 ;; used and dosage. State whether any is a corticosteroid
18 ;; or other immunosuppresive drug. State whether medications
19 ;; used are systemic or topical. Describe whether intensive
20 ;; light therapy, UVB, PUVA, or electron beam therapy are used.
21 ;;
22 ;;
23 ;; 3. For EACH treatment, report the frequency of use and duration
24 ;; of treatment during the past 12-month period.
25 ;;
26 ;;
27 ;; 4. Describe any side effects of treatment.
28 ;;
29 ;;
30 ;; 5. Describe local (skin) symptoms and any systemic symptoms,
31 ;; such as fever or weight loss.
32 ;;
33 ;;
34 ;; 6. For malignant neoplasms of skin, additionally describe
35 ;; all treatment, including date and type of last treatment.
36 ;;
37 ;;
38 ;; 7. For benign neoplasms of skin, additionally describe any
39 ;; impairment of function.
40 ;;
41 ;;
42 ;; 8. For urticaria, primary cutaneous vasculitis, and
43 ;; erythema multiforme, additionally describe the number of
44 ;; episodes during the past 12-month period, whether the
45 ;; episodes are debilitating, how they are treated, and
46 ;; whether they respond to treatment.
47 ;;
48 ;;C. Physical Examination (Objective Findings):
49 ;;
50 ;; 1. Report extent of disease - specify if any exposed areas
51 ;; (head, face, neck, and hands) are affected and the PERCENT
52 ;; OF EXPOSED AREAS that is affected and specify the PERCENT
53 ;; OF THE ENTIRE BODY that is affected.
54 ;;
55 ;;
56 ;; 2. If there is scarring or disfigurement, follow the "Scars"
57 ;; worksheet in addition to this one.
58 ;;
59 ;;
60 ;; 3. For acne or chloracne, describe whether the acne is
61 ;; superficial (with comedones, papules, pustules, superficial
62 ;; cysts) or deep (with deep inflamed nodules and pus-filled
63 ;; cysts), which areas of the body are affected, and,
64 ;; specifically, the PERCENT OF FACE AND NECK affected.
65 ;;
66 ;;
67 ;; 4. For scarring alopecia, describe the PERCENT OF THE SCALP
68 ;; that is affected.
69 ;;
70 ;;
71 ;; 5. For alopecia areata, describe whether there is loss of all
72 ;; body hair or whether loss of hair is limited to the scalp
73 ;; and face.
74 ;;
75 ;;
76 ;; 6. For hyperhidrosis, state whether veteran is able to handle
77 ;; paper or tools after therapy, or is unable to handle paper
78 ;; or tools because of moisture and is unresponsive to therapy.
79 ;;
80 ;;D. Diagnostic and Clinical Tests:
81 ;;
82 ;; 1. Biopsy, scrapings if indicated.
83 ;; 2. Include results of all diagnostic and clinical tests conducted
84 ;; in the examination report.
85 ;; 3. With disfigurement or disfiguring scar of head, face, or
86 ;; neck, submit COLOR PHOTOGRAPHS.
87 ;; 4. Test for hypoproteinemia if examining for exfoliative
88 ;; dermatitis (erythroderma).
89 ;;
90 ;;E. Diagnosis:
91 ;;
92 ;;
93 ;;Signature: Date:
94 ;;END
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