source: WorldVistAEHR/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWTD1.m@ 1375

DVBCWTD1 ;ALB/CMM THYROID DISEASES WKS TEXT - 1 ; 5 MARCH 1997
 ;;2.7;AMIE;**12**;Apr 10, 1995
 ;
 ;
TXT ;
 ;;A.  Review of Medical Records:
 ;;
 ;;
 ;;
 ;;B.  Medical History (Subjective Complaints):
 ;;
 ;;    Comment on:
 ;;    1.  Date diagnosis established.
 ;;
 ;;
 ;;    2.  Fatigability.
 ;;
 ;;
 ;;    3.  Mental assessment.
 ;;
 ;;
 ;;    4.  Neurologic, cardiovascular, or gastrointestinal symptoms.
 ;;
 ;;
 ;;    5.  Treatments (surgery, medications, hormones), including dose, 
 ;;        frequency, response, side effects.  For C-cell hyperplasia, 
 ;;        provide date of completion of any treatment for malignancy.
 ;;
 ;;
 ;;    6.  Symptoms due to pressure (on larynx, esophagus, etc.).
 ;;
 ;;
 ;;    7.  Cold or heat intolerance.
 ;;
 ;;
 ;;    8.  Constipation.
 ;;
 ;;
 ;;    9.  Weight gain or loss.
 ;;
 ;;
 ;;C.  Physical Examination (Objective Findings):
 ;;
 ;;    Address each of the following and fully describe current findings:
 ;;    1.  Thyroid size.
 ;;
 ;;
 ;;    2.  Pulse and blood pressure.
 ;;
 ;;
 ;;    3.  Eye and vision abnormalities.
 ;;
 ;;
 ;;    4.  Muscle strength.
 ;;
 ;;
 ;;    5.  Tremor.
 ;;
 ;;
 ;;    6.  Myxedema.
 ;;
 ;;
 ;;    7.  All other residuals of thyroid disease or its treatment.
 ;;
 ;;
 ;;D.  Diagnostic and Clinical Tests:
 ;;
 ;;    Provide:
 ;;    1.  T4, T3, TSH, and/or other thyroid function tests, if needed.
 ;;    2.  If thyroidectomy scar is disfiguring, order color photograph.
 ;;    3.  Thyroid scan, if indicated.
 ;;    4.  Include results of all diagnostic and clinical tests conducted
 ;;        in the examination report.
 ;;
 ;;
 ;;E.  Diagnosis:
 ;;
 ;;    Comment on:
 ;;    1.  Is the disease active or in remission? 
 ;;
 ;;
 ;;Signature:                             Date:
 ;;END